Healthy California Act: proposal to make findings about single-payer healthcare(leginfo.legislature.ca.gov)
leginfo.legislature.ca.gov
Healthy California Act: proposal to make findings about single-payer healthcare
http://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB562
467 comments
A well-executed single-payer system would make California even more attractive for entrepreneurship and increase labor mobility for everyone. Life would be much easier if we could start companies or switch jobs without worrying about healthcare.
Completely agree. The trick is making sure it's well-executed so that other states can use it as a template. Once one state proves that single-payer can be done well, I suspect it will cascade inevitably.
With 100% seriousness, if the ACA is repealed I will likely be choosing between Massachusetts (where Romneycare would hopefully take priority again) or another country. It's too risky to do otherwise.
My extended and immediate family members have too many horror stories about being denied coverage or it being prohibitively expensive. Like a cousin who had to choose working over being a stay-at-home mom to take care of her kids, since her husband's policy as an entrepreneur wouldn't cover her. She didn't even have any ongoing health problems, just a technical pre-existing condition.
I am unwilling to be stuck in a job or forced to accept unreasonable compensation or a nasty work environment because I have to have health coverage. Which is a decision too many in my family have been forced to make. Many family members (including myself) have far worse chronic illnesses, so it's utterly involuntary -- work or die. And thankfully I have a choice in where to live by virtue of my education and credentials.
I have been blessed so far to not have to deal with it because I've only lived in MA as an adult prior to Obamacare -- where Romneycare was in place by the time I finished undergrad. But I've heard enough first hand accounts and seen the suffering that kind of horrible choice creates. And the absolutely perverse incentives it puts onto the job market, and onto individuals. Health care is not a voluntary market, and treating it like one is bonkers.
Now I'm in California. I seriously doubt I will be able to stay without a guarantee that I can manage medical expenses, and I'm definitively privileged economically compared to the majority of the US population.
With 100% seriousness, if the ACA is repealed I will likely be choosing between Massachusetts (where Romneycare would hopefully take priority again) or another country. It's too risky to do otherwise.
My extended and immediate family members have too many horror stories about being denied coverage or it being prohibitively expensive. Like a cousin who had to choose working over being a stay-at-home mom to take care of her kids, since her husband's policy as an entrepreneur wouldn't cover her. She didn't even have any ongoing health problems, just a technical pre-existing condition.
I am unwilling to be stuck in a job or forced to accept unreasonable compensation or a nasty work environment because I have to have health coverage. Which is a decision too many in my family have been forced to make. Many family members (including myself) have far worse chronic illnesses, so it's utterly involuntary -- work or die. And thankfully I have a choice in where to live by virtue of my education and credentials.
I have been blessed so far to not have to deal with it because I've only lived in MA as an adult prior to Obamacare -- where Romneycare was in place by the time I finished undergrad. But I've heard enough first hand accounts and seen the suffering that kind of horrible choice creates. And the absolutely perverse incentives it puts onto the job market, and onto individuals. Health care is not a voluntary market, and treating it like one is bonkers.
Now I'm in California. I seriously doubt I will be able to stay without a guarantee that I can manage medical expenses, and I'm definitively privileged economically compared to the majority of the US population.
California had guaranteed issue before the ACA. Any small business with at least 2 employees could get it. Premiums were reasonable as the "rating adjustment factor" was capped on these plans. A one time 6 month waiting period on pre-existing conditions is waived if you have prior credible coverage without more than a 62 day gap in coverage.
For example, a husband and wife working together in a sole proprietorship, would qualify.
I'm not sure the current state since ACA passed, but I depended on CA guaranteed issue myself for several years before ACA and it provided access to high quality expensive insurance (~$500 / person / month) with unlimited annual benefits, as well as somewhat cheaper HMO plans (~$350-400 / person / month).
Google 'AB 1672'.
For example, a husband and wife working together in a sole proprietorship, would qualify.
I'm not sure the current state since ACA passed, but I depended on CA guaranteed issue myself for several years before ACA and it provided access to high quality expensive insurance (~$500 / person / month) with unlimited annual benefits, as well as somewhat cheaper HMO plans (~$350-400 / person / month).
Google 'AB 1672'.
Thanks, very helpful to know. Most of my family is in Ohio, and I'm a recent transplant to California.
This appears to be the updated version of AB 1672, which itself ended in 2013:
http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?...
I'm not remotely capable of parsing all the stuff in there, but it does make me wonder what happens when a State passes a bill to bring itself into compliance with a Federal law and then the Federal law is repealed. I assume it's not automatic that the State bill ceases to function.
Is this even more of an uncertainty-laden mess than I thought? Will dozens of states find that changes to the ACA is interacting in crazy ways with state laws? Somehow I am guessing that we won't find out until it happens.
This appears to be the updated version of AB 1672, which itself ended in 2013:
http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?...
I'm not remotely capable of parsing all the stuff in there, but it does make me wonder what happens when a State passes a bill to bring itself into compliance with a Federal law and then the Federal law is repealed. I assume it's not automatic that the State bill ceases to function.
Is this even more of an uncertainty-laden mess than I thought? Will dozens of states find that changes to the ACA is interacting in crazy ways with state laws? Somehow I am guessing that we won't find out until it happens.
> ... stuck in a job or forced to accept unreasonable compensation or a nasty work environment because I have to have health coverage.
Which is what makes this a huge political issue and an incredible leverage point.
I wish we could unite and end the use of healthcare coverage / availability to enslave workers ("enslave" being used loosely for the ones Who are as pedantic as I sometimes am).
Which is what makes this a huge political issue and an incredible leverage point.
I wish we could unite and end the use of healthcare coverage / availability to enslave workers ("enslave" being used loosely for the ones Who are as pedantic as I sometimes am).
> It's too risky to do otherwise.
Uh, you could just buy insurance yourself. It's not like no-ones covered unless the State writes the check. smh
Uh, you could just buy insurance yourself. It's not like no-ones covered unless the State writes the check. smh
This is the point where America discovers European liberal political theory and praxis! This is one of their key points; universal healthcare is a hard-L liberal position because only the state can insure certain classes of catastrophic risk, and by doing so you increase individual freedom of action.
(European liberalism is clearly culturally distinct from social democratic thought; where it comes to the same positions it's typically by other means – not that there's anything wrong with social democracy or democratic Socialism, for that matter.)
A good starting point would be, at pan-Europe level, the ALDE; https://en.wikipedia.org/wiki/Alliance_of_Liberals_and_Democ.... National-level parties you might have heard of are the Liberal Democrats (UK) and Democraten 66 (Netherlands).
(European liberalism is clearly culturally distinct from social democratic thought; where it comes to the same positions it's typically by other means – not that there's anything wrong with social democracy or democratic Socialism, for that matter.)
A good starting point would be, at pan-Europe level, the ALDE; https://en.wikipedia.org/wiki/Alliance_of_Liberals_and_Democ.... National-level parties you might have heard of are the Liberal Democrats (UK) and Democraten 66 (Netherlands).
Very much agree. I wrote this about single payer, entrepreneurship and my time in Italy:
https://journal.dedasys.com/2017/02/22/entrepreneurship-and-...
https://journal.dedasys.com/2017/02/22/entrepreneurship-and-...
I managed to crash my bike in to a car in Italy; I remember the process of going to a doctor (which happened to be the closest door on the sidewalk where I hobbled over to) and having them send me to a hospital. I got looked at, xrayed, and given a diagnosis without having to even talk about money or anything beyond a 4-line form for my information.
Single-payer is wonderful, and I believe an absolute necessity as we march towards a future of automation and enormous economic inequality.
Single-payer is wonderful, and I believe an absolute necessity as we march towards a future of automation and enormous economic inequality.
Thanks for sharing! I also lived in Berlin for four years and was impressed with how easy healthcare was.
I don't think anyone disagrees that single payer requires higher taxes than we currently pay. so given that, you're trying to tell me that a state with the highest taxes (much much higher than #2) in the nation, with the lowest housing affordability will attract more entrepreneurs than before?
why? because the young and invincible will be choose cheaper healthcare over being able to live comfortably? I highly doubt it. this has nothing to do with whether or not single payer is a good idea. I just did the idea that people will choose CA over cheaper states just for that reason
why? because the young and invincible will be choose cheaper healthcare over being able to live comfortably? I highly doubt it. this has nothing to do with whether or not single payer is a good idea. I just did the idea that people will choose CA over cheaper states just for that reason
I can't speak for everyone else, but the two reasons that were holding me back as an employee of a large corporation instead of starting my own company were employer-provided healthcare and visa restrictions at the moment. This measure would have eliminated one of those major constraints.
CA #1? What are you talking about? The state with the highest tax burden is NY. CA doesn't even make it to the top 10.
https://wallethub.com/edu/states-with-highest-lowest-tax-bur...
https://wallethub.com/edu/states-with-highest-lowest-tax-bur...
California has the highest income tax rate in the nation which directly impacts entrepreneurs starting a business (if they are successful and create wealth). Why would any sane person want to shave off an extra 13 cents for every dollar they make when they're already losing 40 cents per dollar from the federal government? This is why many entrepreneurs are choosing states with low or no income tax and leaving CA and their hyper-liberal state gov behind.
[http://www.cpapracticeadvisor.com/news/12281147/irs-income-t...]
[http://www.cpapracticeadvisor.com/news/12281147/irs-income-t...]
> Why would any sane person want to shave off an extra 13 cents for every dollar they make when they're already losing 40 cents per dollar from the federal government?
The beautiful weather, the beautiful people, the amazing weather, the topographical diversity that allows you to surf and snowboard on the same day, the amazing hikes, the national parks, the ability to bike to work year round. Silicon Valley "manages" to attract a lot of entrepreneurs, but maybe you think they're all insance?
You could eliminate all taxes and I still wouldn't choose to live in Texas or Florida. You could increase my salary 10x and I wouldn't move to Nebraska, the Dakotas, Arkansas, Oklahoma, Kansas, or Iowa. Then again, you could hire for remote positions if you need devs.
The beautiful weather, the beautiful people, the amazing weather, the topographical diversity that allows you to surf and snowboard on the same day, the amazing hikes, the national parks, the ability to bike to work year round. Silicon Valley "manages" to attract a lot of entrepreneurs, but maybe you think they're all insance?
You could eliminate all taxes and I still wouldn't choose to live in Texas or Florida. You could increase my salary 10x and I wouldn't move to Nebraska, the Dakotas, Arkansas, Oklahoma, Kansas, or Iowa. Then again, you could hire for remote positions if you need devs.
I think you added the wrong link, which I had assumed was a reference to your claim that "many entrepreneurs are choosing states with low or no income tax". It appears to just be a link to Federal tax brackets. Do you have something to actually back up that claim?
I ask because it's very counterintuitive -- entrepreneurs are pretty much never showing much personal income for years since it's all in equity. And by the time they are making that much personal income, they're presumably just as well off as a normal employee with that income.
The only things I ever hear about that incentivize startups to move somewhere are the (a) ecosystem of support (b) availability of low cost facilities and (c) state tax credits or grant award opportunities, such as matching grants with federal SBIR grants.
I have literally never heard an entrepreneur suggest moving to a new state because of personal income taxes. If personal income is high enough that it's a problem, they're probably well enough off that they can afford it regardless of whether they're an entrepreneur or not.
Unless maybe you're talking about how progressive taxes in general do a bad job at the whole variable income thing. I hear lots of complaints about that with regard to personal income taxes from friends who are more contractor/consulting focused. But that's also not a California thing.
I ask because it's very counterintuitive -- entrepreneurs are pretty much never showing much personal income for years since it's all in equity. And by the time they are making that much personal income, they're presumably just as well off as a normal employee with that income.
The only things I ever hear about that incentivize startups to move somewhere are the (a) ecosystem of support (b) availability of low cost facilities and (c) state tax credits or grant award opportunities, such as matching grants with federal SBIR grants.
I have literally never heard an entrepreneur suggest moving to a new state because of personal income taxes. If personal income is high enough that it's a problem, they're probably well enough off that they can afford it regardless of whether they're an entrepreneur or not.
Unless maybe you're talking about how progressive taxes in general do a bad job at the whole variable income thing. I hear lots of complaints about that with regard to personal income taxes from friends who are more contractor/consulting focused. But that's also not a California thing.
Your link doesn't prove anything it's just a federal tax.
The other reply posted a link and California does not have the highest income tax rate, it's 4th.
So from the get go your premise is false.
Also liberal or not you're stating an opinion of why hypothetical companies should do this and that, all the while we still have Silicon Valley and Hollywood in California. So in the face of reality you have not yet successfully prove or convincingly argue that high tax will drive away companies.
The other reply posted a link and California does not have the highest income tax rate, it's 4th.
So from the get go your premise is false.
Also liberal or not you're stating an opinion of why hypothetical companies should do this and that, all the while we still have Silicon Valley and Hollywood in California. So in the face of reality you have not yet successfully prove or convincingly argue that high tax will drive away companies.
You mean, other than the insane people at: Apple, Google, Facebook, Twitter, Oracle, HP, Uber... Clearly some successful entrepreneurs find that the 13 cents to still be worth it to have access to the talent and ecosystem. Perhaps there is something about liberal policies that encourages more successful entrepreneurism. Massachusetts, with best-in-the-nation insurance coverage thanks to RomneyCare also as an outsized tech scene.
I remember these arguments made when Jerry Brown first proposed the newer upper income tax bands in 2009.
Considering, for a very long time, California's taxes have been the highest in the country (to be fair, definitely not "much much higher" than NYC,) last I checked it was adding jobs at a higher percentage rate than any other state.
Do you really think there's been an entrepreneur exodus from the Bay Area and LA since 2009?
Considering, for a very long time, California's taxes have been the highest in the country (to be fair, definitely not "much much higher" than NYC,) last I checked it was adding jobs at a higher percentage rate than any other state.
Do you really think there's been an entrepreneur exodus from the Bay Area and LA since 2009?
But don't you know? He learned in econ 101 that high tax rates are bad! Why he's Basically a Nobel prize winning economist!
I don't think anyone disagrees that single payer requires higher taxes than we currently pay
The first problem is, how could the government simply take over? Eminent Domain? Constitutional amendment?
True, but the parent was speaking specifically to taxes alone, while your reply is referring to a different claim, about taxes plus healthcare costs.
> I disagree, in the sense that I don't take that as a given.
Well it depends who you're talking to. If you're poor, the impact on your income tax will be nothing. If you're like me, i.e. you have a fantastic employer plan with an annual premium amounting to ~4% of your annual salary, then you can bet your ass you'll be paying more in taxes and getting a worse product to boot.
Well it depends who you're talking to. If you're poor, the impact on your income tax will be nothing. If you're like me, i.e. you have a fantastic employer plan with an annual premium amounting to ~4% of your annual salary, then you can bet your ass you'll be paying more in taxes and getting a worse product to boot.
Would be great. Also would be great if two states could join up and offer single payer together.
West coast single payer?
Doesn't seem like a hard sell to get Oregon & Washington on board, politically.
WA isn't even meeting its constitutional mandate for funding education.
I'd like to learn more about this, can you provide a source?
But it would require the consent of Congress, per the Constitution:
"No State shall, without the Consent of Congress... enter into any Agreement or Compact with another State."
I don't see that happening.
"No State shall, without the Consent of Congress... enter into any Agreement or Compact with another State."
I don't see that happening.
IANAL, but the wikipedia page on Interstate Compact states that "Not all compacts between states require explicit Congressional approval - the Supreme Court ruled in Virginia v. Tennessee that only those agreements which would increase the power of states at the expense of the federal government required it."
I'm not sure this would cause the federal government to lose any power, especially if the ACA was repealed.
Also, if the bill allowing for interstate healthcare exchanges were passed it would seem to imply that states are allowed to cooperate on healthcare?
I'm not sure this would cause the federal government to lose any power, especially if the ACA was repealed.
Also, if the bill allowing for interstate healthcare exchanges were passed it would seem to imply that states are allowed to cooperate on healthcare?
It would be great if it goes this way. I would guess that the Feds would sue to stop it in spite and to protect insurance companies and then it would go to the Supreme Court.
There are people working on that for the interior mountain states.
I'd be okay with single-payer in CA if we implemented the system in Denmark. Great mix of "everyone is covered" with choice/doctor control. I wish more people wanted it. :(
If we're just going to keep doing the ACA, no thanks. What a piece of shit that legislation turned out to be.
If we're just going to keep doing the ACA, no thanks. What a piece of shit that legislation turned out to be.
Great point.
It would be good as a baseline, then companies can offer supplement plans for additional coverage or a wider network, similar to Medicare.
It would be good as a baseline, then companies can offer supplement plans for additional coverage or a wider network, similar to Medicare.
Here's the only thing I'm confused about. Do we have examples of the government running a service better than the private sector?
I'm not 100% on this, but it seems all of the best aspects of American services come from competition and letting capitalism thrive.
Would love a counter opinion.
I'm not 100% on this, but it seems all of the best aspects of American services come from competition and letting capitalism thrive.
Would love a counter opinion.
You would do well to start questioning the idea that the private sector does anything "better". After all, it was them that gave us Enron, Deepwater Horizon, and most recently, the subprime mortgage crisis, which brought the entire world economy to its knees. Those are only a few examples that spring to mind.
In addition, comparing the government with the private sector is pretty silly. They have different goals. Private companies try to maximize profit, even if it comes with massive externalities (which, barring regulations, they happily pass on to others). Governments aim to serve their citizens, even if it comes at the expense of efficiency. This means that any given problem will be handled very differently by the private sector compared to the government. The route we pick really depends on our priorities as a society.
In addition, comparing the government with the private sector is pretty silly. They have different goals. Private companies try to maximize profit, even if it comes with massive externalities (which, barring regulations, they happily pass on to others). Governments aim to serve their citizens, even if it comes at the expense of efficiency. This means that any given problem will be handled very differently by the private sector compared to the government. The route we pick really depends on our priorities as a society.
After all, it was them that gave us Enron, Deepwater Horizon, and most recently, the subprime mortgage crisis, which brought the entire world economy to its knees.
That's a pretty poor argument if you line it up against gov't waste, incompetence and corruption.
That's a pretty poor argument if you line it up against gov't waste, incompetence and corruption.
Can you provide any arguments (or, even better, empirical evidence) as to why the government has more waste, incompetence and corruption than the private sector?
I'm not arguing one is better than the other. Just that both system are run by humans so I wouldn't say you'd have less corruption or waste in one or the other.
I can vote out government representatives; I cannot vote out unregulated companies doing damage in a marketplace.
Government provided services provide the opportunity for total transparency; this is not the case in the private sector.
EDIT: @refurb: You're confusing a free market with what the United States has. A free market it ain't (especially regarding healthcare).
Government provided services provide the opportunity for total transparency; this is not the case in the private sector.
EDIT: @refurb: You're confusing a free market with what the United States has. A free market it ain't (especially regarding healthcare).
In a free market you can chose to go with another company.
Provide me with an example of a fully functioning free market completely devoid if any government regulation or involvement?
If one doesn't exist, I wouldn't like our system to move into that direction based upon wild speculation and pure theory. The implicit assumption in free market models is that people are rational agents, when all research shows that people are highly irrational.
Wouldn't you like see evidence of how a free market would function on the scale of the United States? Like a scientist, not like a religious zealot?
If one doesn't exist, I wouldn't like our system to move into that direction based upon wild speculation and pure theory. The implicit assumption in free market models is that people are rational agents, when all research shows that people are highly irrational.
Wouldn't you like see evidence of how a free market would function on the scale of the United States? Like a scientist, not like a religious zealot?
In a "freely competitive market" (to use Adam Smith's original phrase) you can. In a market without that competition you can't. Sadly many markets in practice don't have free competition.
Do you get to choose your isp? What about your crude oil? Do you know where it originated?
Well, yeah, we aren't really disagreeing then.
I'll take it and democratic representation over corporate waste, incompetence and corruption.
In fact, the reason government sucks right now is that corporations/wealthy have rigged the game by buying representation average citizens can't compete with (legalized corruption = lobbying).
In fact, the reason government sucks right now is that corporations/wealthy have rigged the game by buying representation average citizens can't compete with (legalized corruption = lobbying).
Off the top of my head, and certainly some are up for debate. But consider how well these systems worked prior to government intervention.
You may think medicare, for instance, is run horribly -- but I'm pretty confident that seniors are far happier with it than they were pawning off their possessions to get medical treatment prior to it being created.
- Medicaid
- Medicare
- The USPS (which, let's be honest, is freaking amazing for the price)
- Social security
- Basic research
- The military (remember our private security contractors and how much more horrible they were?)
- The fire department
- The police (can you imagine how horrible a private police force would be?)
And on the flip side, consider how atrocious private prisons are compared to federally operated ones.
I'm sure there are many, many others...
You may think medicare, for instance, is run horribly -- but I'm pretty confident that seniors are far happier with it than they were pawning off their possessions to get medical treatment prior to it being created.
- Medicaid
- Medicare
- The USPS (which, let's be honest, is freaking amazing for the price)
- Social security
- Basic research
- The military (remember our private security contractors and how much more horrible they were?)
- The fire department
- The police (can you imagine how horrible a private police force would be?)
And on the flip side, consider how atrocious private prisons are compared to federally operated ones.
I'm sure there are many, many others...
> You may think medicare, for instance, is run horribly -- but I'm pretty confident that seniors are far happier with it than they were pawning off their possessions to get medical treatment prior to it being created.
Sure, but empirically, seniors are far happier with privatized Medicare plans than they are with publicly-administered Medicare plans. Original Medicare has the lowest satisfaction rates of all major Medicare plans - far lower than the lowest of the privately-managed plans.
Medicaid is run at the state level, but the same applies there as well - privately managed Medicaid plans are gaining popularity because they deliver better medical results at lower prices.
> The USPS (which, let's be honest, is freaking amazing for the price)
USPS is a mixed bag, but it isn't a straightforward comparison, because the USPS is statutorily protected from competition. For example, by law, all private carriers are required to charge at least twice what USPS charges for a first-class letter - so when you say it's "amazing for the price", we're already dealing with a warped perception of what mail delivery costs.
Most of the other examples you list don't address OP's question ("Do we have examples of the government running a service better than the private sector"), because there hasn't been a private sector for those in modern history for us to compare them with.
Sure, but empirically, seniors are far happier with privatized Medicare plans than they are with publicly-administered Medicare plans. Original Medicare has the lowest satisfaction rates of all major Medicare plans - far lower than the lowest of the privately-managed plans.
Medicaid is run at the state level, but the same applies there as well - privately managed Medicaid plans are gaining popularity because they deliver better medical results at lower prices.
> The USPS (which, let's be honest, is freaking amazing for the price)
USPS is a mixed bag, but it isn't a straightforward comparison, because the USPS is statutorily protected from competition. For example, by law, all private carriers are required to charge at least twice what USPS charges for a first-class letter - so when you say it's "amazing for the price", we're already dealing with a warped perception of what mail delivery costs.
Most of the other examples you list don't address OP's question ("Do we have examples of the government running a service better than the private sector"), because there hasn't been a private sector for those in modern history for us to compare them with.
If the proposals on the table were to simply allow private companies to offer competing options, I would have few concerns that I could back up with factual analysis.
I suspect it would be highly case-by-case, which is fine and how a deliberative legislative body should function. I'd still be extremely leery of private police, military, fire, or infrastructure, it just seems like a transparently bad idea.
Like our security contractors paid by the military, who cost vastly more than public employees and have far less oversight. And who (possibly coincidentally, but come on) are to blame for the worst abuses by our forces overseas.
But for some specific, narrow market (like space travel or health care or even retirement funds) I'd be absolutely willing to give them a chance as long as it didn't break the existing government system.
Charter schools seem like a good case study in that, which I say not because the data completely backs up the idea that government run is always better, but because it's a very complex system with many examples that provide insight in both directions.
I suspect it would be highly case-by-case, which is fine and how a deliberative legislative body should function. I'd still be extremely leery of private police, military, fire, or infrastructure, it just seems like a transparently bad idea.
Like our security contractors paid by the military, who cost vastly more than public employees and have far less oversight. And who (possibly coincidentally, but come on) are to blame for the worst abuses by our forces overseas.
But for some specific, narrow market (like space travel or health care or even retirement funds) I'd be absolutely willing to give them a chance as long as it didn't break the existing government system.
Charter schools seem like a good case study in that, which I say not because the data completely backs up the idea that government run is always better, but because it's a very complex system with many examples that provide insight in both directions.
> Medicaid is run at the state level, but the same applies there as well - privately managed Medicaid plans are gaining popularity because they deliver better medical results at lower prices.
This is disputable. Private companies are also motivated by greed which means they'll cut corners to save penies.
This is disputable. Private companies are also motivated by greed which means they'll cut corners to save penies.
> Would love a counter opinion.
Every other first world country?
https://en.wikipedia.org/wiki/List_of_countries_with_univers...
Every other first world country?
https://en.wikipedia.org/wiki/List_of_countries_with_univers...
Several of those countries implement universal coverage using a private insurance model.
In almost all European countries, its provided by the government and funded by taxation. My point stands.
Netherlands, Germany and Switzerland are 3 counter examples.
Germany doesn't have single-payer, but it does have a highly-regulated, mostly public health insurance industry. Most people are covered by the public system, which, while multi-payer, has premiums set by the government and based on income, as well as a fixed set of services determined by the government.
In effect, it's not that different from a single-payer system funded by a progressive income tax. I have thought the German system might be a better fit for the US, since sickness funds can still compete with each other, mostly on customer service and the like.
In effect, it's not that different from a single-payer system funded by a progressive income tax. I have thought the German system might be a better fit for the US, since sickness funds can still compete with each other, mostly on customer service and the like.
All the best systems are single payer. Italy, France, Spain, the UK. The countries with private insurance like Germany are middle of the pack. Clearly single payer is the superior option.
Having lived in both countries, I wouldn't say that the UK system is in any way better than the German system. Rather the opposite.
In addition to that, the German system isn't really a private system. The premium and health coverage is set by law and the insurances are not-for-profit entities. There's the possibility to get private insurance for parts of the population, but you're not dependent on private companies.
In addition to that, the German system isn't really a private system. The premium and health coverage is set by law and the insurances are not-for-profit entities. There's the possibility to get private insurance for parts of the population, but you're not dependent on private companies.
Back that up with numbers please. At best, the former four are better in terms of value-for-money, but with experience living in both the former and the latter, the German system is superior in terms of outcomes, waiting times, choice.
(Yes, mediterranean countries have a higher life expectancy due to diet and physical activity, but that wouldn't change much with a different health care model.)
(Yes, mediterranean countries have a higher life expectancy due to diet and physical activity, but that wouldn't change much with a different health care model.)
My primary contention is that Every other first world country? is a little too lacking in nuance, I wasn't trying to express an opinion about what works best.
Parent comment still addresses the point. Majority of first-world countries have single-payer model. Exceptions prove the rule.
Prisons for one.
You seem to misunderstand the role of governments though. Citizens and taxpayers are not shareholders seeking to maximize return on investment. The government exists to provide for national defense, rule of law, postal service, and domestic security. Private industry would have an incentive to not provide these services for free riders (the poor, those who dodge payment, etc.)
Private industry also ignores externalities in their pricing, which is why we have regulation. I quite like not having to pay for relatively clean air.
You seem to misunderstand the role of governments though. Citizens and taxpayers are not shareholders seeking to maximize return on investment. The government exists to provide for national defense, rule of law, postal service, and domestic security. Private industry would have an incentive to not provide these services for free riders (the poor, those who dodge payment, etc.)
Private industry also ignores externalities in their pricing, which is why we have regulation. I quite like not having to pay for relatively clean air.
Many. Start with highways, aviation safety, and prisons. Oh, and the history of private fire departments is a carnival of horrors. I mean, the list goes on (and on, and on).
> Here's the only thing I'm confused about. Do we have examples of the government running a service better than the private sector?
Medicare is a good case study, because Medicare has both publicly managed plans and privately managed plans.
As it turns out Medicare Advantage (the privately managed plans) consistently beat Original Medicare on the three primary metrics: cost, medical outcomes, and patient satisfaction scores.
(In fact, Original Medicare has the lowest satisfaction rates of all major Medicare plans).
Medicare is a good case study, because Medicare has both publicly managed plans and privately managed plans.
As it turns out Medicare Advantage (the privately managed plans) consistently beat Original Medicare on the three primary metrics: cost, medical outcomes, and patient satisfaction scores.
(In fact, Original Medicare has the lowest satisfaction rates of all major Medicare plans).
Even easier if people could just let others take care of _every_ whim. If there was a guaranteed income there wouldn't even be a need for entrepreneurship!
If anything, people would be more likely to start their own businesses if they had a guaranteed income, because it would mitigate the opportunity cost of quitting their day job.
Yes they would be more likely, but they wouldn't need to.
If you'd like to see what people actually would do with money provided by a basic income program, here are the results of a survery conducted by GiveDirectly, a company piloting the idea in Kenya.
It seems that despite your conjecture, there are a number of people investing the income into education, fishing nets, seeds for crops/livestock, fishing nets, beauty salon's, etc.
In my experience, poor people are the world's greatest entrepreneurs. Every day, they must innovate in order to survive. They remain poor because they do not have the opportunities to turn their creativity into sustainable income.
It seems that despite your conjecture, there are a number of people investing the income into education, fishing nets, seeds for crops/livestock, fishing nets, beauty salon's, etc.
In my experience, poor people are the world's greatest entrepreneurs. Every day, they must innovate in order to survive. They remain poor because they do not have the opportunities to turn their creativity into sustainable income.
I feel as if there was a misunderstanding, because I fully agree with you.
the interesting thing to me is why didn't CA make these moves under Obama if they thought they had such a better plan for healthcare... either way it's a win for DT
Urgency does wonders for the political process.
Donald Trump would love to claim some sort of credit, I'm sure.
Fortunately the world moves on independent of his desires.
Fortunately the world moves on independent of his desires.
Vermont tried this a few years ago, they had to cancel it since in the end it wasn't financially feasible [1]. CA is already dealing with severe budget issues [2][3], so while it sounds nice in theory I'm hesitant to believe the finances actually work out.
[1] http://www.politico.com/story/2014/12/single-payer-vermont-1...
[2] http://www.latimes.com/projects/la-me-pension-crisis-davis-d...
[3] http://www.cnbc.com/2016/05/26/californias-revenue-picture-d...
[1] http://www.politico.com/story/2014/12/single-payer-vermont-1...
[2] http://www.latimes.com/projects/la-me-pension-crisis-davis-d...
[3] http://www.cnbc.com/2016/05/26/californias-revenue-picture-d...
[2] is about CalPERS, which is separate from the budget of the State. There may be a current budget shortfall, but CalPERS is fine (it is the largest non-country pension fund in the world; and comes in the top 10 when listed among countries).
[3] mentions that tax revenues will fall because of the end of temporary tax increases; those increases are likely to be renewed.
Categorizing these as 'severe budget issues' is disingenuous and misleading. California has had a bumper crop in terms of tax revenue over the past decade, and this stupid meme about California being out of money needs to be corrected.
That being said, health care is not an inexpensive line-item, and will have to be funded with taxes.
But as a Californian, I'm sure as shit happy to pay more in taxes for a universal single single-payer. I have many friends who are either contractors or who earn very little and find themselves in that uncomfortable valley of having to pay for expensive insurance -- I'd rather that people (like me) who are better off financially foot a bit more of a communal bill so that no one would need to worry about it.
[3] mentions that tax revenues will fall because of the end of temporary tax increases; those increases are likely to be renewed.
Categorizing these as 'severe budget issues' is disingenuous and misleading. California has had a bumper crop in terms of tax revenue over the past decade, and this stupid meme about California being out of money needs to be corrected.
That being said, health care is not an inexpensive line-item, and will have to be funded with taxes.
But as a Californian, I'm sure as shit happy to pay more in taxes for a universal single single-payer. I have many friends who are either contractors or who earn very little and find themselves in that uncomfortable valley of having to pay for expensive insurance -- I'd rather that people (like me) who are better off financially foot a bit more of a communal bill so that no one would need to worry about it.
California has had a bumper crop in terms of tax revenue
And this doesn't even count the huge infrastructure deficiencies and deferred maintenance.
[0] http://www.pressdemocrat.com/news/6563825-181/19-billion-err...
Another thing I'm finding out is that states have been playing accounting gimmicks and moving funds about accounts that should not have been mixed up as they were...
tens of thousands of local government entities issue bonds, and some employ dubious accounting techniques “that obscure their true financial position,” according to a 2015 report of the Volcker Alliance https://www.city-journal.org/html/zeroing-government-fraud-1...
tens of thousands of local government entities issue bonds, and some employ dubious accounting techniques “that obscure their true financial position,” according to a 2015 report of the Volcker Alliance https://www.city-journal.org/html/zeroing-government-fraud-1...
> it is the largest non-country pension fund in the world; and comes in the top 10 when listed among countries
Yes, and that's the problem. It's funding is at 73% and dropping -- that 27% is an astronomical deficit.
Numbers here: https://www.calpers.ca.gov/page/newsroom/calpers-news/2017/a...
Yes, and that's the problem. It's funding is at 73% and dropping -- that 27% is an astronomical deficit.
Numbers here: https://www.calpers.ca.gov/page/newsroom/calpers-news/2017/a...
Thanks for the details regarding the budget, I didn't realize the pension budget shortfall was separate from the state budget.
In that case stupid question: if CalPERS owes much more than it can afford to pay, where is the rest coming from? The LA Times article, in multiple places, talks about how much the shortage will cost the "taxpayers" (see quote below for example), how is this not related to the CA budget which is, well, funded by taxpayers?
> "This year, state employee pensions will cost taxpayers $5.4 billion, according to the Department of Finance. That’s more than the state will spend on environmental protection, fighting wildfires and the emergency response to the drought combined."
That makes it seem like it's related to the budget...
In that case stupid question: if CalPERS owes much more than it can afford to pay, where is the rest coming from? The LA Times article, in multiple places, talks about how much the shortage will cost the "taxpayers" (see quote below for example), how is this not related to the CA budget which is, well, funded by taxpayers?
> "This year, state employee pensions will cost taxpayers $5.4 billion, according to the Department of Finance. That’s more than the state will spend on environmental protection, fighting wildfires and the emergency response to the drought combined."
That makes it seem like it's related to the budget...
They will either have to increase contributions or cut payments to future retirees.
As if those are the only two options... what happens when the unions plans their strikes for the week before a major event, like transit workers before the DNC here in Philly?
Also, when tax-free pension contributions go up and taxable payments to future retirees go down... then taxes collected also goes down...
Also, when tax-free pension contributions go up and taxable payments to future retirees go down... then taxes collected also goes down...
They strike they strike. It's happened before, it will happen again.
As for a change in tax revenue, the same is true if you contribute more to your 401k and/or get back less because your investments didn't do good. Also, if you lay state employees off, your state income tax revenues go down.
As for a change in tax revenue, the same is true if you contribute more to your 401k and/or get back less because your investments didn't do good. Also, if you lay state employees off, your state income tax revenues go down.
It is related to the budget, but not directly related since it is promises to fund pensions rather than something directly related to government services.
It could be funded by increasing contributions gradually until it reaches the correct funding level (either from cuts in other areas or taxes), by cutting the future amounts they distribute from the pensions, by raising the retirement rate of current workers which would give them time to make up the deficit, or a combination of these.
The problem is, these options all kind of stink politically, but they won't bankrupt the state by themselves.
It could be funded by increasing contributions gradually until it reaches the correct funding level (either from cuts in other areas or taxes), by cutting the future amounts they distribute from the pensions, by raising the retirement rate of current workers which would give them time to make up the deficit, or a combination of these.
The problem is, these options all kind of stink politically, but they won't bankrupt the state by themselves.
>I'm sure as shit happy to pay more in taxes for a universal single single-payer.
As someone who just climbed out of being a contractor and into a full time position, I concur. Raise my taxes for this. Please do it, and do it soon.
As someone who just climbed out of being a contractor and into a full time position, I concur. Raise my taxes for this. Please do it, and do it soon.
Not to mention that detaching health insurance from employment is sure to create a lot more fluid labor market (contracting would be easier, part time work becomes more viable, etc....).
Uhh, no thanks. I'd rather be able to decide for myself what healthcare I buy, instead of being forced into a substandard single payer system.
Ok, fine, create a public option. But don't force me to buy it. Let me buy my own healthcare.
Ok, fine, create a public option. But don't force me to buy it. Let me buy my own healthcare.
This is what Australia does, I think. Single payer public option, but you can choose to buy private health care as well (though you still pay taxes for the public option regardless). I'm curious to hear from any Australians about how this system works for them.
I use to work pretty well for me. Note I haven't been there in 4 years.
When I left if you earnt over (iirc) 40k per year, you had to purchase private health insurance. Im happy with that.
I did have to goto hospital a few times, I shattered my elbow joint and required 3 surgeries to repair it in total.
The cost was under 5k in total if I remember correctly. I went to public hospital first, but for something like this they recommended private(which I had at the time) - that way there was less waiting, 2 days later I was having my first surgery.
When I left if you earnt over (iirc) 40k per year, you had to purchase private health insurance. Im happy with that.
I did have to goto hospital a few times, I shattered my elbow joint and required 3 surgeries to repair it in total.
The cost was under 5k in total if I remember correctly. I went to public hospital first, but for something like this they recommended private(which I had at the time) - that way there was less waiting, 2 days later I was having my first surgery.
It seems to work okay for the most part, and the population of Australia is much smaller than that of California so I don't believe it would be impossible to do by itself. There are always political discussions in the background about changes to cost or services, but it has a high level of public support across the spectrum of politics, which helps.
The main thing to consider is that the tax base is much different from the U.S. There is an across the board GST which is managed federally, so no local/state options. The income tax overall is higher, though the part that is earmarked specifically for healthcare is only a small percentage of overall income tax. This means that general revenues make up a larger portion of funding than it would appear from a single item on your paystub.
Also, the pricing for public health services is heavily regulated, though there are completely private hospitals and clinics that are separate from that system. Ambulance is also separate from the system, which means either a local tax in some areas or you would need to pay for insurance coverage.
Overall, patient cost is lower, but take-home pay is also lower. Also, I don't believe you can make a sustainable public system without also having a large number of regulated "public" clinics and hospitals. If done correctly, I believe there would be alot of buy in from doctors and other professionals who are just as tired of dealing with the payment headaches as patients are. But you have to get alot of buy in from both them and patients to make it work, and you need an option for people who want to pay for their own "cadillac plans" if you want to keep insurance companies and the very wealthy from getting upset at the effect on choice and lifestyle.
The main thing to consider is that the tax base is much different from the U.S. There is an across the board GST which is managed federally, so no local/state options. The income tax overall is higher, though the part that is earmarked specifically for healthcare is only a small percentage of overall income tax. This means that general revenues make up a larger portion of funding than it would appear from a single item on your paystub.
Also, the pricing for public health services is heavily regulated, though there are completely private hospitals and clinics that are separate from that system. Ambulance is also separate from the system, which means either a local tax in some areas or you would need to pay for insurance coverage.
Overall, patient cost is lower, but take-home pay is also lower. Also, I don't believe you can make a sustainable public system without also having a large number of regulated "public" clinics and hospitals. If done correctly, I believe there would be alot of buy in from doctors and other professionals who are just as tired of dealing with the payment headaches as patients are. But you have to get alot of buy in from both them and patients to make it work, and you need an option for people who want to pay for their own "cadillac plans" if you want to keep insurance companies and the very wealthy from getting upset at the effect on choice and lifestyle.
[deleted]
Yes, this is how things work Down Under.
There is a universal public health care system that everyone is part of and funded via Federal Govt taxes. This allows anyone to be treated for free in a public hospital. Given your condition and severity of the problem, you may have to wait for treatment.
This system works quiet well overall.
There is also a parallel private insurance system and privately owned hospitals. Which you may choose to be treated in if you have/can afford the insurance. Top private insurance cover for a family can run to about AUD$5,000 per year.
If you earn over a certain amount of money a year ($90,000+ for singles and $180,000+ for families) you will pay more tax if you do not have private insurance. This is to try and push those that can afford private insurance and treatment into the private system, to free up resources in the public system.
There is a universal public health care system that everyone is part of and funded via Federal Govt taxes. This allows anyone to be treated for free in a public hospital. Given your condition and severity of the problem, you may have to wait for treatment.
This system works quiet well overall.
There is also a parallel private insurance system and privately owned hospitals. Which you may choose to be treated in if you have/can afford the insurance. Top private insurance cover for a family can run to about AUD$5,000 per year.
If you earn over a certain amount of money a year ($90,000+ for singles and $180,000+ for families) you will pay more tax if you do not have private insurance. This is to try and push those that can afford private insurance and treatment into the private system, to free up resources in the public system.
Deleted because the sibling comment posted at the same time is more thorough.
You actually pay more taxes if you do not choose the private option. Though private insurance is generally more expensive. Over the years since it was introduced, there was an exodus of sorts from public to private due to this incentive. It has recently started to turn as insurance companies have been drawing more profit than the value they provide.
It helps that the standard of care in Australia, for significant or life-threatening health situations at least, is generally as good if not better in the public system. For everything else, insurance or otherwise, the only way to get quality healthcare is money and contacts.
As a system of encouraging higher spends on healthcare, private insurance works.. The only issue is none of the profits of that system goes towards better healthcare. It is just more damn rent.
It helps that the standard of care in Australia, for significant or life-threatening health situations at least, is generally as good if not better in the public system. For everything else, insurance or otherwise, the only way to get quality healthcare is money and contacts.
As a system of encouraging higher spends on healthcare, private insurance works.. The only issue is none of the profits of that system goes towards better healthcare. It is just more damn rent.
I know others replied but I'll try to do a full, in-depth explanation of how it works here because the alternative is that I do producive work after lunch and screw that.
Everyone earning a taxable income pays a "medicare levy" of 2% of your total taxable income which funds the public system [1]. You pay that regardless of whether you use it or not - it's a fixed part of your income taxes. There are waivers for low income earners as detailed in [1] so that teens working in cafes to get through uni aren't smacked with extra taxes but by and large if you're a fulltime employee you'll be probably paying it.
In addition to that, you pay another 1-1.5% of your total income (1% for $90-105k, 1.25% for $105-140k and 1.5% for 140k+) as the "medicare levy surcharge" [2], however you get a partial or full refund of this if you have private health insurance. This encourages high income earners to take out private health insurance, ostensibly to shift the burden off the public health system because if they have private insurance they're more inclined to use it.
Lastly, if you do not take out private health insurance once you turn 30, your premiums on private health insurance increase by 2% per year for every year that you don't hold it over 30 (with some exceptions) [3]. After 10 years of paying this increased loading on fees, it disappears (ie: if you take out private health insurance for the first time at 40 you'll be paying 120% premiums until 50 then it'll drop back to 100%). This is supposed to incentivise people to take it out earlier in life and hold on to it, rather than take it out towards the end of life when they get sick all the time. By doing so, it (in theory, i'm dubious) keeps down premiums for everyone overall because private insurance companies don't have to price in people only buying it when they're sick.
As for how this works, I think it works pretty good on balance. Everyone gets a green medicare card at age 18 (under 18 they're on their parents one, unless broken families etc. necessitate an individual one earlier) and it entitles you to basically walk in to a public hospital and get care if you need it, though the public system usually requires waits based on your current state (ie: even if you're in emergency with a broken wrist, they'll put you aside with some painkillers if there's someone with an exploding appendix presenting at the same time). It also covers other procedures that are non-life-threatening, though there's significant (months+) wait times - you go see a specialist who registers you into the public system for a procedure, then you wait until you get a letter in the mail setting a date for your procedure. Even for semi-urgent procedures there might be waits of months depending on how muc hdemand there is, though to their credit the public system does try to keep tabs on whether your health degrades during that time and will prioritise you accordingly relative to others waiting for the same procedure.
I had a completely non-life-threatning, almost cosmetic surgical procedure in the public system and I was waiting for about a year or so but given it had no effect on my day to day life I was happy to wait and it meant it was completely free. I saw my GP and he referred me to a specialist (who I think saw me under the public system, so I didn't pay for that). I saw the specialist and he scheduled me for the procedure. When I got my date for it, I went in mid-morning, went under a local, woke up a few hours later and walked home that afternoon with absolutely no out-of-pocket cost to me whatsoever.
The quality of healthcare is reasonable too - many of the specialists who work in the public system also work in the private system for a couple of days a week to boost their income, so it's not uncommon for a specialist you consult with to ask which way you want to go before they direct you to whichever relevant hospital they practice at. The public system also tries to facilitate cross-hospital discussions about particuarly interesting cases, for example doctors from multiple public hospitals in a city will come together to share notes and ask for opinions to help deliver better outcomes. Private, by nature, doesn't necessarily get that exposure.
The private health insurance system here is national - just about anyone in any state can get any policy, more or less. There's easy comparison websites that let you plug in your details and get a quote [4] and they offer all kinds of ranges of cover from 'I want to avoid the surchage for tax purposes, please insure me as minimally as possible' (at about $70/mo in my experience) to 'I want to be able to walk in to a private hospital for absolutely any reason and not pay a cent, please charge me all of the money in fees' ($x00s/mo easily from what I've seen). Cover is sliced into 'basic hospital' cover and 'extras' cover which lets you tailor the two with greater flexibility. Changing between providers is nearly frictionless and that helps keep fees down since they're all competing. The government does place some regulation on the levels of fees and how much they may increase each year, to try to manage costs of private insurance. There's also strict rules governing pre-existing conditions, etc. that you hear about from US insurance horror stories.
The public system is not without its faults for sure, and many people will rubbish the public system as a bad one due to its wait times, its relatively reduced level of personal focus by staff, increased patient:staff ratios etc. but it does remarkably well for the funding it has and is vastly preferable to it not existing. Those who want a private experience can easily get it but those who can't afford it at least won't rock up to a hospital with a broken foot only to be turned away. In that sense, it serves its purpose well as there's the incentive for people to pay to move off the public system (thus managing its burden) whilst ensuring that if you absolutely do need help, you'll get it.
[1]: https://www.ato.gov.au/Individuals/Medicare-levy/
[2]: https://www.ato.gov.au/Individuals/Tax-Return/2016/Tax-retur...
[3]: http://www.privatehealth.gov.au/healthinsurance/incentivessu...
[4]: http://www.iselect.com.au/ as an example if you want to play around
Everyone earning a taxable income pays a "medicare levy" of 2% of your total taxable income which funds the public system [1]. You pay that regardless of whether you use it or not - it's a fixed part of your income taxes. There are waivers for low income earners as detailed in [1] so that teens working in cafes to get through uni aren't smacked with extra taxes but by and large if you're a fulltime employee you'll be probably paying it.
In addition to that, you pay another 1-1.5% of your total income (1% for $90-105k, 1.25% for $105-140k and 1.5% for 140k+) as the "medicare levy surcharge" [2], however you get a partial or full refund of this if you have private health insurance. This encourages high income earners to take out private health insurance, ostensibly to shift the burden off the public health system because if they have private insurance they're more inclined to use it.
Lastly, if you do not take out private health insurance once you turn 30, your premiums on private health insurance increase by 2% per year for every year that you don't hold it over 30 (with some exceptions) [3]. After 10 years of paying this increased loading on fees, it disappears (ie: if you take out private health insurance for the first time at 40 you'll be paying 120% premiums until 50 then it'll drop back to 100%). This is supposed to incentivise people to take it out earlier in life and hold on to it, rather than take it out towards the end of life when they get sick all the time. By doing so, it (in theory, i'm dubious) keeps down premiums for everyone overall because private insurance companies don't have to price in people only buying it when they're sick.
As for how this works, I think it works pretty good on balance. Everyone gets a green medicare card at age 18 (under 18 they're on their parents one, unless broken families etc. necessitate an individual one earlier) and it entitles you to basically walk in to a public hospital and get care if you need it, though the public system usually requires waits based on your current state (ie: even if you're in emergency with a broken wrist, they'll put you aside with some painkillers if there's someone with an exploding appendix presenting at the same time). It also covers other procedures that are non-life-threatening, though there's significant (months+) wait times - you go see a specialist who registers you into the public system for a procedure, then you wait until you get a letter in the mail setting a date for your procedure. Even for semi-urgent procedures there might be waits of months depending on how muc hdemand there is, though to their credit the public system does try to keep tabs on whether your health degrades during that time and will prioritise you accordingly relative to others waiting for the same procedure.
I had a completely non-life-threatning, almost cosmetic surgical procedure in the public system and I was waiting for about a year or so but given it had no effect on my day to day life I was happy to wait and it meant it was completely free. I saw my GP and he referred me to a specialist (who I think saw me under the public system, so I didn't pay for that). I saw the specialist and he scheduled me for the procedure. When I got my date for it, I went in mid-morning, went under a local, woke up a few hours later and walked home that afternoon with absolutely no out-of-pocket cost to me whatsoever.
The quality of healthcare is reasonable too - many of the specialists who work in the public system also work in the private system for a couple of days a week to boost their income, so it's not uncommon for a specialist you consult with to ask which way you want to go before they direct you to whichever relevant hospital they practice at. The public system also tries to facilitate cross-hospital discussions about particuarly interesting cases, for example doctors from multiple public hospitals in a city will come together to share notes and ask for opinions to help deliver better outcomes. Private, by nature, doesn't necessarily get that exposure.
The private health insurance system here is national - just about anyone in any state can get any policy, more or less. There's easy comparison websites that let you plug in your details and get a quote [4] and they offer all kinds of ranges of cover from 'I want to avoid the surchage for tax purposes, please insure me as minimally as possible' (at about $70/mo in my experience) to 'I want to be able to walk in to a private hospital for absolutely any reason and not pay a cent, please charge me all of the money in fees' ($x00s/mo easily from what I've seen). Cover is sliced into 'basic hospital' cover and 'extras' cover which lets you tailor the two with greater flexibility. Changing between providers is nearly frictionless and that helps keep fees down since they're all competing. The government does place some regulation on the levels of fees and how much they may increase each year, to try to manage costs of private insurance. There's also strict rules governing pre-existing conditions, etc. that you hear about from US insurance horror stories.
The public system is not without its faults for sure, and many people will rubbish the public system as a bad one due to its wait times, its relatively reduced level of personal focus by staff, increased patient:staff ratios etc. but it does remarkably well for the funding it has and is vastly preferable to it not existing. Those who want a private experience can easily get it but those who can't afford it at least won't rock up to a hospital with a broken foot only to be turned away. In that sense, it serves its purpose well as there's the incentive for people to pay to move off the public system (thus managing its burden) whilst ensuring that if you absolutely do need help, you'll get it.
[1]: https://www.ato.gov.au/Individuals/Medicare-levy/
[2]: https://www.ato.gov.au/Individuals/Tax-Return/2016/Tax-retur...
[3]: http://www.privatehealth.gov.au/healthinsurance/incentivessu...
[4]: http://www.iselect.com.au/ as an example if you want to play around
Would you need a refund?
Would you be OK with a requirement that you do, in fact, spend the refund on health insurance?
Otherwise I see a problem where struggling people opt out of the care, to get cash to pay for other emergencies, and then the state ends up footing emergency room bills anyway, and premiums are out of whack due to decreased enrollment by healthy people.
Also, what happens if your private care falls short and you show up one day at the State emergency room? Do we refuse you care because you opted out? Emergency rooms need to give care to everyone, that's the point it's an emergency and you don't want to have your care waiting on your paperwork being out of order in an emergency.
If we can reserve part of your refund to cover such situations, I'm ok with it!
Would you be OK with a requirement that you do, in fact, spend the refund on health insurance?
Otherwise I see a problem where struggling people opt out of the care, to get cash to pay for other emergencies, and then the state ends up footing emergency room bills anyway, and premiums are out of whack due to decreased enrollment by healthy people.
Also, what happens if your private care falls short and you show up one day at the State emergency room? Do we refuse you care because you opted out? Emergency rooms need to give care to everyone, that's the point it's an emergency and you don't want to have your care waiting on your paperwork being out of order in an emergency.
If we can reserve part of your refund to cover such situations, I'm ok with it!
How do you know it will be substandard?
From my travels to New Zealand, I'd argue their single-payer health care experience is overall better than here. You can buy private insurance there which supplements the public system and lets you visit private hospitals outside of the public systems, but you don't need it for emergencies or standard GP checkups. Most people don't bother since the public system is good.
And from a tax perspective, according to the BBC, the US effectively taxes an average income single person at 22.7% while NZ taxes at 16.4% [1]. For the top bracket, in US it is 39.6% while in NZ it is 33% [2][3]. I'd argue they are getting a much better deal than us. And don't forget the US numbers are before health insurance is paid.
So, it is definitely possible to get a good system. I think one of our major problems as a country is that we lack transparency which undermines trust and makes it easier to corrupt the system. You can't run a good health care system without transparency and accountability, regardless of whether it is a public or private system.
Cheers!
[1] http://www.bbc.com/news/magazine-26327114 [2] https://www.irs.gov/pub/irs-pdf/i1040gi.pdf [3] http://www.ird.govt.nz/how-to/taxrates-codes/rates/itaxsalar...
From my travels to New Zealand, I'd argue their single-payer health care experience is overall better than here. You can buy private insurance there which supplements the public system and lets you visit private hospitals outside of the public systems, but you don't need it for emergencies or standard GP checkups. Most people don't bother since the public system is good.
And from a tax perspective, according to the BBC, the US effectively taxes an average income single person at 22.7% while NZ taxes at 16.4% [1]. For the top bracket, in US it is 39.6% while in NZ it is 33% [2][3]. I'd argue they are getting a much better deal than us. And don't forget the US numbers are before health insurance is paid.
So, it is definitely possible to get a good system. I think one of our major problems as a country is that we lack transparency which undermines trust and makes it easier to corrupt the system. You can't run a good health care system without transparency and accountability, regardless of whether it is a public or private system.
Cheers!
[1] http://www.bbc.com/news/magazine-26327114 [2] https://www.irs.gov/pub/irs-pdf/i1040gi.pdf [3] http://www.ird.govt.nz/how-to/taxrates-codes/rates/itaxsalar...
Most people are provided healthcare through work and are not given an option of what healthcare to buy.
I can understand it, but it's basically a classist system. The advocates are saying rich people are better than everyone else, they should be able to bribe their way into better health care because they can afford to. A single payer system that puts everyone, regardless of race, class, age, at the end of the line - and as they do not like how things work, they fix it. What's important is creating the auditing mechanisms for identifying and evaluating problems, prioritizing them, and then getting them fixed.
But the reality is, the for-profit system already forces people into a substandard single payer system in a huge portion of the U.S. where there's only one insurer, not least because health insurance is an anti-competitive business but aren't regulated per competition law.
But the reality is, the for-profit system already forces people into a substandard single payer system in a huge portion of the U.S. where there's only one insurer, not least because health insurance is an anti-competitive business but aren't regulated per competition law.
> is about CalPERS, which is separate from the budget of the State. There may be a current budget shortfall, but CalPERS is fine
It's 'separate' from the state budget, but doesn't California still ultimately pay for pensions? How is this fine when there's a huge difference between the projected costs and the actual costs? Doesn't 70% of CA tax revenue go towards paying pension obligations?
Current CA pension debt is $965 Billion.
http://news.stanford.edu/2015/10/15/cali-pension-tracker-101...
http://www.pensiontracker.org/index.php
It's 'separate' from the state budget, but doesn't California still ultimately pay for pensions? How is this fine when there's a huge difference between the projected costs and the actual costs? Doesn't 70% of CA tax revenue go towards paying pension obligations?
Current CA pension debt is $965 Billion.
http://news.stanford.edu/2015/10/15/cali-pension-tracker-101...
http://www.pensiontracker.org/index.php
Doesn't 70% of CA tax revenue go towards paying pension obligations
Maybe you got the 70% figure from where CalPERS gets its funding? Currently yearly contribution is ~70% from the state, but there was a bill passed that is shifting some of the requirement on to those who will benefit from it.
I'm not sure why both of our comments got downvoted, but thanks for the clarification.
Yes there was a new bill and there was a shift, but most of the burden is still on the state of California which makes sense since CALPERS is an agency of the state of California. Isn't CA still ultimately responsible for CA pensions?
I just felt that CALPERS was in trouble years ago when they were selling their members an advancement in years for the pension if they paid a fee upfront (which could be deducted from their paychecks) in order to meet current pension obligations.
Current CA pension debt is $965 Billion. It'll become $1 Trillion soon.
http://www.pensiontracker.org/index.php
Yes there was a new bill and there was a shift, but most of the burden is still on the state of California which makes sense since CALPERS is an agency of the state of California. Isn't CA still ultimately responsible for CA pensions?
I just felt that CALPERS was in trouble years ago when they were selling their members an advancement in years for the pension if they paid a fee upfront (which could be deducted from their paychecks) in order to meet current pension obligations.
Current CA pension debt is $965 Billion. It'll become $1 Trillion soon.
http://www.pensiontracker.org/index.php
> as a Californian...I'd rather that people like me...
There is crux of the issue: not everyone shares the same opinion and belief, so should the government force those people to spend their earned income on healthcare for others? Personally I think it won't end up how you anticipate but that's just me. Right now the working people of America are already subsidizing healthcare for the masses and all I ever hear is people complaining about it.
There is crux of the issue: not everyone shares the same opinion and belief, so should the government force those people to spend their earned income on healthcare for others? Personally I think it won't end up how you anticipate but that's just me. Right now the working people of America are already subsidizing healthcare for the masses and all I ever hear is people complaining about it.
>not everyone shares the same opinion and belief, so should the government force those people to spend their earned income on healthcare for others?
Yes. Ideally, that's what governments should do: require citizens to act in our collective and long-term best interests, not only their own.
In the case of healthcare: a healthy population is a productive, happy, and peaceful population. All of those things are good for the economy, not to mention any one particular person's soul -- you can make a completely utilitarian argument for it and largely sidestep thorny issues of morality.
Yes. Ideally, that's what governments should do: require citizens to act in our collective and long-term best interests, not only their own.
In the case of healthcare: a healthy population is a productive, happy, and peaceful population. All of those things are good for the economy, not to mention any one particular person's soul -- you can make a completely utilitarian argument for it and largely sidestep thorny issues of morality.
most likely what will happen is people will just leave CA, leaving a shortage and it will fail
> most likely what will happen is people will just leave CA
Could you please inform our population here about that?
Republicans keep promising that people will flee the Blue states due to various policies; somehow it never seems to happen.
Could you let us know what we're doing wrong? We'd really like to send some of these folks to Red states to help balance out the voting.
Thanks bunches.
Could you please inform our population here about that?
Republicans keep promising that people will flee the Blue states due to various policies; somehow it never seems to happen.
Could you let us know what we're doing wrong? We'd really like to send some of these folks to Red states to help balance out the voting.
Thanks bunches.
http://www.sacbee.com/news/state/california/article136478098...
"Every year from 2000 through 2015, more people left California than moved in from other states. This migration was not spread evenly across all income groups, a Sacramento Bee review of U.S. Census Bureau data found. The people leaving tend to be relatively poor, and many lack college degrees. Move higher up the income spectrum, and slightly more people are coming than going.
About 2.5 million people living close to the official poverty line left California for other states from 2005 through 2015, while 1.7 million people at that income level moved in from other states – for a net loss of 800,000. During the same period, the state experienced a net gain of about 20,000 residents earning at least five times the poverty rate – or $100,000 for a family of three."
Life in California is becoming a luxury good, largely due to its own policies, and that is not a state in the right direction.
"Every year from 2000 through 2015, more people left California than moved in from other states. This migration was not spread evenly across all income groups, a Sacramento Bee review of U.S. Census Bureau data found. The people leaving tend to be relatively poor, and many lack college degrees. Move higher up the income spectrum, and slightly more people are coming than going.
About 2.5 million people living close to the official poverty line left California for other states from 2005 through 2015, while 1.7 million people at that income level moved in from other states – for a net loss of 800,000. During the same period, the state experienced a net gain of about 20,000 residents earning at least five times the poverty rate – or $100,000 for a family of three."
Life in California is becoming a luxury good, largely due to its own policies, and that is not a state in the right direction.
Do people migrate out of EU states with universal health care? They have free movement and everything.
I think this would actually be another great lock-in feature, on top of rent control and Prop 13 making it so nobody would ever want to sell their house.
I think this would actually be another great lock-in feature, on top of rent control and Prop 13 making it so nobody would ever want to sell their house.
> Yes. Ideally, that's what governments should do: require citizens to act in our collective and long-term best interests, not only their own.
That's starting to sound a lot like Marxism where the value of the individual is less so than that of the collective (Government / State).
I'm sorry but no thanks. Who determines what our best interest is? The only person on this planet that can determine my best interest is me. If I'm incapable of doing so for myself then that is too bad.
That's starting to sound a lot like Marxism where the value of the individual is less so than that of the collective (Government / State).
I'm sorry but no thanks. Who determines what our best interest is? The only person on this planet that can determine my best interest is me. If I'm incapable of doing so for myself then that is too bad.
It's starting to sound like civilization. When we live together, I don't want to subsidize your poor decisions.
If you want to live your life alone in a forest somewhere, you can pay no tax and make all your own decisions.
If you want to live your life alone in a forest somewhere, you can pay no tax and make all your own decisions.
What does this have to do with healthcare? Is it a right or a privilege? Your answer to that question makes it clear why we likely disagree.
Healthcare is a SERVICE that someone PROVIDES to you for MONEY. It has a tangible COST. It is not a RIGHT which is something that WE as a COLLECTIVE have determined WE individually possess (liberty, right to bare arms, freedom of press, right to assemble, etc)
That is the bedrock issue behind all the arguments on this topic and why (despite idealistically admirable), universal healthcare will likely never happen...
To make it clear, personally I am not opposed to doing everything we can as a society to bring the cost of healthcare down and make it available and affordable to as many people as possible. But to guarantee blanket coverage for ~325M people is not realistic.
Healthcare is a SERVICE that someone PROVIDES to you for MONEY. It has a tangible COST. It is not a RIGHT which is something that WE as a COLLECTIVE have determined WE individually possess (liberty, right to bare arms, freedom of press, right to assemble, etc)
That is the bedrock issue behind all the arguments on this topic and why (despite idealistically admirable), universal healthcare will likely never happen...
To make it clear, personally I am not opposed to doing everything we can as a society to bring the cost of healthcare down and make it available and affordable to as many people as possible. But to guarantee blanket coverage for ~325M people is not realistic.
To add on to the comment of seanmcdirmid
Adding up the population[1] (in millions, rounded down) of all countries in Europe with universal healthcare[2], except the 144 million from Russia, which is mostly asia anyway, I get to 484 million people covered by universal healthcare.
This includes countries like Germany (81M), France (66M), the UK (65M), Italy (60M) and Spain (46M), which should alleviate the fear of 'small European countries can do that, but not a state as big as California'.
[1] https://en.wikipedia.org/wiki/List_of_European_countries_by_... [2] https://en.wikipedia.org/wiki/List_of_countries_with_univers...
Adding up the population[1] (in millions, rounded down) of all countries in Europe with universal healthcare[2], except the 144 million from Russia, which is mostly asia anyway, I get to 484 million people covered by universal healthcare.
This includes countries like Germany (81M), France (66M), the UK (65M), Italy (60M) and Spain (46M), which should alleviate the fear of 'small European countries can do that, but not a state as big as California'.
[1] https://en.wikipedia.org/wiki/List_of_European_countries_by_... [2] https://en.wikipedia.org/wiki/List_of_countries_with_univers...
But there are more than 325 million people covered by socialized medicine in the EU. Why is that unrealistic?
Heck, it could even help our economy, because you probably don't buy your own health insurance anyways, but get it from work. Take away that burden from the companies, and it could actually make them more competitive.
Heck, it could even help our economy, because you probably don't buy your own health insurance anyways, but get it from work. Take away that burden from the companies, and it could actually make them more competitive.
It seems like most of the complaints about healthcare now relate to unpredictable costs and complexity though. I'm not sure the simplicity and stress-reduction of a single-payer system really are appreciated. I'm Canadian, and our system is fair from perfect. That said, it's hard for me to comprehend the stories I regularly read about people's experiences in the American system, trying to decide on plans, sacrificing care due to cost, even just having to figure out what hospital they can go to when they need one. All this hassle has an effect that's significant but difficult to quantify.
I even have one personal anecdote - on a recent trip to Disneyland with some friends, a friend of mine got sick and needed to see a doctor. He had purchased travel insurance, so called the insurance company to figure out where to go. It turned out that the only walk-in clinics covered were halfway across LA. There were other clinics within blocks of our hotel, but they weren't covered. So, he basically wasted an entire day. Now, compared to serious healthcare issues, obviously this isn't a big deal. But still, the experience was just alien to us. Here, if you need to see a doctor, you either book an appointment with your family doctor, or if you need to see someone sooner or it's more convenient or whatever, you just go to a clinic. Any clinic doctor will see you, and will bill MSP (the provincial health plan).
Again, our system isn't perfect. Compared to someone with good coverage in the US, our wait lists for major procedures are generally longer. It's occasionally debated whether private clinics should be allowed to perform these procedures, allowing people who can afford it to jump the queue. The theory is that this leaves more public resources for everyone else, so it's win-win. However, generally politicians steer clear of anything that sounds like private health care, because in general people fear any erosion of the public system. (For example by having good doctors go to private clinics.)
Anyway, that was a bit of a tangent. The point is, there are intangible benefits to single payer healthcare that I don't see often discussed in the US.
I even have one personal anecdote - on a recent trip to Disneyland with some friends, a friend of mine got sick and needed to see a doctor. He had purchased travel insurance, so called the insurance company to figure out where to go. It turned out that the only walk-in clinics covered were halfway across LA. There were other clinics within blocks of our hotel, but they weren't covered. So, he basically wasted an entire day. Now, compared to serious healthcare issues, obviously this isn't a big deal. But still, the experience was just alien to us. Here, if you need to see a doctor, you either book an appointment with your family doctor, or if you need to see someone sooner or it's more convenient or whatever, you just go to a clinic. Any clinic doctor will see you, and will bill MSP (the provincial health plan).
Again, our system isn't perfect. Compared to someone with good coverage in the US, our wait lists for major procedures are generally longer. It's occasionally debated whether private clinics should be allowed to perform these procedures, allowing people who can afford it to jump the queue. The theory is that this leaves more public resources for everyone else, so it's win-win. However, generally politicians steer clear of anything that sounds like private health care, because in general people fear any erosion of the public system. (For example by having good doctors go to private clinics.)
Anyway, that was a bit of a tangent. The point is, there are intangible benefits to single payer healthcare that I don't see often discussed in the US.
As a Canadian as well, I appreciate you being up front about the drawbacks of our system as well. I've heard so many American's say "oh, the Canadian system is so much better". Is it better in coverage? Obviously!
However, when I ask if they'd be ok waiting over a year for joint replacement surgery, they get a weird look on their face. Or, if they have cancer, they aren't going to get to go to the best cancer center in Canada, you go to your local hospital. And if you want the latest and greatest cancer treatment? Well, you'll need to pay for that yourself since the gov't hasn't yet approved it for reimbursement.
There are benefits to both systems, but it's disingenuous to say that a single payer system solves all problems.
However, when I ask if they'd be ok waiting over a year for joint replacement surgery, they get a weird look on their face. Or, if they have cancer, they aren't going to get to go to the best cancer center in Canada, you go to your local hospital. And if you want the latest and greatest cancer treatment? Well, you'll need to pay for that yourself since the gov't hasn't yet approved it for reimbursement.
There are benefits to both systems, but it's disingenuous to say that a single payer system solves all problems.
These situations are common in the U.S., unless you are well-connected and can pull strings.
> waiting over a year for joint replacement surgery
1) Remember that many Americans have no access to healthcare outside of emergency rooms; they wait forever. I know plenty, including connected people, who wait months for simple appointments. A year before surgery wouldn't surprise me at all.
> if they have cancer, they aren't going to get to go to the best cancer center in Canada, you go to your local hospital.
2) Again, many Americans wait forever. Few others go to the best treatment centers in the nation - how much capacity do those places have, and who is filling up the local facilities?
> if you want the latest and greatest cancer treatment? Well, you'll need to pay for that yourself since the gov't hasn't yet approved it for reimbursement.
3) Again, some Americans get no funding. Most others are limited to what their insurance companies cover and often have the same problems.
> waiting over a year for joint replacement surgery
1) Remember that many Americans have no access to healthcare outside of emergency rooms; they wait forever. I know plenty, including connected people, who wait months for simple appointments. A year before surgery wouldn't surprise me at all.
> if they have cancer, they aren't going to get to go to the best cancer center in Canada, you go to your local hospital.
2) Again, many Americans wait forever. Few others go to the best treatment centers in the nation - how much capacity do those places have, and who is filling up the local facilities?
> if you want the latest and greatest cancer treatment? Well, you'll need to pay for that yourself since the gov't hasn't yet approved it for reimbursement.
3) Again, some Americans get no funding. Most others are limited to what their insurance companies cover and often have the same problems.
I'm not arguing that many people would be better off. I'm arguing that many people would have to lower their expectations around healthcare.
There is a very big chunk of the US that has very expensive (that they can afford) and very good healthcare.
There is a very big chunk of the US that has very expensive (that they can afford) and very good healthcare.
Couldn't they still pay extra and get it? Can't you do that in Canada?
Nope! Physicians either have to be a part of the public system 100% or 0%. No doing both.
As a result, there are very few private options for healthcare in Canada.
As a result, there are very few private options for healthcare in Canada.
A family member of mine is an orthopedic surgeon in Vancouver. Several years ago he split his time between a teaching hospital and a private practice, doing knee surgeries at both. At the hospital waiting times were typical. At his private practice waiting times were very short, on the order of days, I think. IIRC, the way surgeons get around the rules is by charging by the hour, not by the procedure. And it's completely out-of-pocket. For the kind of cookie-cutter, out-patient operations he specialized in it worked very well for him and his well-heeled patients.
Right. As I mentioned in my post, there is a concern that allowing otherwise would erode the public system. Perhaps it's justified; I don't know. Also, those who can afford it can travel to the US or elsewhere if they want to pay for services, which reduces the motivation to create a private alternative here, although it turns out in practice that happens rarely. This is a good overview, also covering the differences in wait times between the systems: https://motherboard.vice.com/en_us/article/fact-checking-tru...
And yet. We have a system where the rich are OK and the poor can be destroyed by an encounter with the health care system.
A system where almost everyone is OK and the rich can pay for the best care available is far, far preferable.
A system where almost everyone is OK and the rich can pay for the best care available is far, far preferable.
How many Americans do you think get to go and get their cancer treated at Memorial Sloan Kettering?
The US private health care system doesn't mean everyone who gets cancer goes to MD Anderson. And, you'd still be very hard pressed to have many private insurance plans cover truly experimental treatments. If I had to choose who gets advanced treatments between those who can pay the most vs those who need it the most I'd go with the latter.
It's funny, many of my Canadian friends talk about the "you can't get the best treatment in the world" problem with their system which, to me, shows how they really don't understand the dire nature of US health care. Wait a year for a surgery? Millions of Americans can only go to emergency rooms.
The US private health care system doesn't mean everyone who gets cancer goes to MD Anderson. And, you'd still be very hard pressed to have many private insurance plans cover truly experimental treatments. If I had to choose who gets advanced treatments between those who can pay the most vs those who need it the most I'd go with the latter.
It's funny, many of my Canadian friends talk about the "you can't get the best treatment in the world" problem with their system which, to me, shows how they really don't understand the dire nature of US health care. Wait a year for a surgery? Millions of Americans can only go to emergency rooms.
I'm not arguing that people in the US don't get care, I'm arguing that if you want to cut healthcare spending in the US (to match other countries) people will have to get used to a lower level of healthcare.
I don't understand what you mean there. I think you underestimate the administrative costs alone of the US' hodgepodge system (an entire floor at UCSF is devoted to insurance processing, how many floors does UBC have for billing?)
The US health care system even for the middle class is a disaster. Deductibles are often nearly 8k or higher alone! And nearly ALL plans have "networks" so you can't go to whatever doctor you want anyway. (One of my canadian friends doesnt even know what a deductible is!)
You realize there are nearly as many Americans without any insurance as there are people in Canada (27M vs 34M)? And this was AFTER the ACA expansion.
I get trying to post an alternative view, but it's so out of wack. Have you experienced the US health care system for an extended period of time personally? It sounds like you haven't.
The US health care system even for the middle class is a disaster. Deductibles are often nearly 8k or higher alone! And nearly ALL plans have "networks" so you can't go to whatever doctor you want anyway. (One of my canadian friends doesnt even know what a deductible is!)
You realize there are nearly as many Americans without any insurance as there are people in Canada (27M vs 34M)? And this was AFTER the ACA expansion.
I get trying to post an alternative view, but it's so out of wack. Have you experienced the US health care system for an extended period of time personally? It sounds like you haven't.
I lived in the US for almost a decade, so I've experienced both systems.
My point is that the US system has problems and the Canadian system has problems. Hell, the Canadian Supreme Court ruled that healthcare wait times combined with a ban on private care violated the Canadian Charter of Rights and Freedoms[1].
There are numerous examples of Canadians either suffering in pain or heading to the US for surgery due to wait times.[2]
Bennett was referred for surgery on her right hip in November of 2013 and said she’s been told she won’t get in until early in 2016. She said her joint has deteriorated so much she is unable to work or even function without strong narcotic painkillers.
[1]https://en.wikipedia.org/wiki/Chaoulli_v_Quebec_(AG) [2]http://www.cbc.ca/news/canada/british-columbia/patients-live...
My point is that the US system has problems and the Canadian system has problems. Hell, the Canadian Supreme Court ruled that healthcare wait times combined with a ban on private care violated the Canadian Charter of Rights and Freedoms[1].
There are numerous examples of Canadians either suffering in pain or heading to the US for surgery due to wait times.[2]
Bennett was referred for surgery on her right hip in November of 2013 and said she’s been told she won’t get in until early in 2016. She said her joint has deteriorated so much she is unable to work or even function without strong narcotic painkillers.
[1]https://en.wikipedia.org/wiki/Chaoulli_v_Quebec_(AG) [2]http://www.cbc.ca/news/canada/british-columbia/patients-live...
[deleted]
I like to remind myself of the complexity of the situation by remembering:
Sometimes Americans go to Canada for medical treatment, and sometimes Canadians come to America for treatment. It's not a simple better/worse situation.
Sometimes Americans go to Canada for medical treatment, and sometimes Canadians come to America for treatment. It's not a simple better/worse situation.
so I recall back in the day when I was in highschool watching a guy on tv blow his brains out on an overpass with a shotgun because apparently his hmo(managed care insurance with a bunch of bullshit rules) screwed him and he couldn't find any recourse other than that.
Just having decent health care is a struggle in america. if you don't have a job and you are not independently wealthy you are basically screwed pre-ACA.
Not having a single payer healthcare in america also changes the risk calculus of starting up your own business.
Just having decent health care is a struggle in america. if you don't have a job and you are not independently wealthy you are basically screwed pre-ACA.
Not having a single payer healthcare in america also changes the risk calculus of starting up your own business.
Yeah, that's pretty much what taxes are for. Funding the government which is what keeps us in line and keeps us from acting like the apes that we are. Part of not being apes is supporting people who won the life-disaster-lottery (which, if you think about it, could be you in 1 year).
The problem with this frame is that it assumes costs under a more socialized system wouldn't budge, making a single-payer system nothing more that simple wealth-transfer.
The thing to recognize is that the every-person-for-themselves approach leads to outcomes that drive costs up extraordinarily. Avoiding the US model is why every other OECD country offers universal coverage and boasts longer lifespans, even though health care costs them one half to two thirds less a portion of their GDP.
For all its bleeding-heart, hippy commie values, the major advantage of single-payer is massively reducing the costs of health care, and making life very hard for anyone not directly creating value. This is bad news for rent-seeking holders of pharma patents and CEOs of private insurance companies making $20 million per year, good news for just about everyone else.
It comes down to this: will you accept that some forms of socialism work in return for getting a better deal on health care and the indirect benefits of living in a society where access is a given? Or are you so ideologically committed to free-market fundamentalism that you would rather waste more of your own money and live in a more unstable society because hey, that's how John Wayne did it.
The thing to recognize is that the every-person-for-themselves approach leads to outcomes that drive costs up extraordinarily. Avoiding the US model is why every other OECD country offers universal coverage and boasts longer lifespans, even though health care costs them one half to two thirds less a portion of their GDP.
For all its bleeding-heart, hippy commie values, the major advantage of single-payer is massively reducing the costs of health care, and making life very hard for anyone not directly creating value. This is bad news for rent-seeking holders of pharma patents and CEOs of private insurance companies making $20 million per year, good news for just about everyone else.
It comes down to this: will you accept that some forms of socialism work in return for getting a better deal on health care and the indirect benefits of living in a society where access is a given? Or are you so ideologically committed to free-market fundamentalism that you would rather waste more of your own money and live in a more unstable society because hey, that's how John Wayne did it.
the major advantage of single-payer is massively reducing the costs of health care
It's cheaper because less is offered. Of course one can argue the extra you get under the US system doesn't really add value.
Keep in mind that single payer systems are struggling with costs as well. It's just easier for them to say "no one gets this new treatment".
It's cheaper because less is offered. Of course one can argue the extra you get under the US system doesn't really add value.
Keep in mind that single payer systems are struggling with costs as well. It's just easier for them to say "no one gets this new treatment".
No, this is demonstrably wrong. Cutting $87,000 in markups from the price of $1,700 off-patent drugs does not mean "less is offered". To the contrary, far more people get access to the drug in question. It may mean that the system as a whole offers far less opportunity to predatory rent-seekers, but that's a feature, not a bug.
And yes, you can very easily argue that many other costs don't add value. That's why pointing to the superior overall life-expectancy in other countries is such an important part of the argument. On balance, every other system in the developed world does more, for more, with less. Our system offers bottom-of-the-pile rankings by every major measure.
Finally, "struggling with costs" is a non-starter as far as arguments against single-payer go since what things cost and how you come up with the money are clearly two different things. Saying "country X is having a hard time funding their health care system at 10% of GDP" in no way undermines the case for dumping a system here in the US that costs us closer to 18% of ours.
Seriously, we could make massive improvements to ours simply by picking the name of any other OECD country from a hat, and just implementing their system. Literally anything is better than what we've got here, and it's not even close.
And yes, you can very easily argue that many other costs don't add value. That's why pointing to the superior overall life-expectancy in other countries is such an important part of the argument. On balance, every other system in the developed world does more, for more, with less. Our system offers bottom-of-the-pile rankings by every major measure.
Finally, "struggling with costs" is a non-starter as far as arguments against single-payer go since what things cost and how you come up with the money are clearly two different things. Saying "country X is having a hard time funding their health care system at 10% of GDP" in no way undermines the case for dumping a system here in the US that costs us closer to 18% of ours.
Seriously, we could make massive improvements to ours simply by picking the name of any other OECD country from a hat, and just implementing their system. Literally anything is better than what we've got here, and it's not even close.
To the contrary, far more people get access to the drug in question.
There are plenty of drugs you can get in the US that single payers systems simply won't cover. The Cancer Fund in the UK is a great example. NHS said "nope too expensive" to several drugs so unless the Cancer Fund pays for it, you're SOL. That's how single payer systems save money.
That's why pointing to the superior overall life-expectancy in other countries is part of the argument.
Life expectancy is a very blunt tool when you're looking at level of healthcare. There is too much intra-country variability.
There are plenty of drugs you can get in the US that single payers systems simply won't cover. The Cancer Fund in the UK is a great example. NHS said "nope too expensive" to several drugs so unless the Cancer Fund pays for it, you're SOL. That's how single payer systems save money.
That's why pointing to the superior overall life-expectancy in other countries is part of the argument.
Life expectancy is a very blunt tool when you're looking at level of healthcare. There is too much intra-country variability.
Part of the reason those drugs exist in the first place is that they've been engineered to extract the maximum amount of cash possible from our nightmare of a system. Yes, you may blow through your lifetime cap on one ailment, but the incentives are in place for pharma makers to see that as much of your cap ends up in their pockets, rather than the competitions. Treatments for Hepatitis-C are one of the more notorious examples of drugs being developed to maximally exploit our system.
The point of controlling costs is to provide incentives for developing drugs that not only work, but that do so at non-ruinous prices.
The point of controlling costs is to provide incentives for developing drugs that not only work, but that do so at non-ruinous prices.
I guess we'll agree to disagree then. I would argue paying tens of thousands of dollars for a cure is a pretty good deal considering the alternatives.
And also, the cost of those HCV therapies is actually cheaper in the US than in the EU.[1]
[1]https://www.forbes.com/sites/johnlamattina/2015/12/04/for-he...
And also, the cost of those HCV therapies is actually cheaper in the US than in the EU.[1]
[1]https://www.forbes.com/sites/johnlamattina/2015/12/04/for-he...
You're just one serious illness or layoff from being one of "those people"
> Right now the working people of America are already subsidizing healthcare for the masses and all I ever hear is people complaining about it.
We do pay for the roads in Los Angeles and EVERYONE complains about the traffic. People bitch about everything
We do pay for the roads in Los Angeles and EVERYONE complains about the traffic. People bitch about everything
Another new account making a trolling comment which adds no knowledge to the conversation.
> all I ever hear is people complaining about it
Government funded healthcare is widely supported in the U.S., including Medicare, Medicaid, and the Affordable Care Act.
> all I ever hear is people complaining about it
Government funded healthcare is widely supported in the U.S., including Medicare, Medicaid, and the Affordable Care Act.
Let's not do the thing where everyone you disagree with is a troll, mmkay?
Have your contractor friends check out NASE. I used to have amazing health coverage through them for about $150 (pre-Obamacare).
> I'm sure as shit happy to pay more in taxes for a universal single single-payer. I
Great, you can opt in to that, but don't force everyone else who doesn't agree with you to subsidize everyone else's poor decisions
Great, you can opt in to that, but don't force everyone else who doesn't agree with you to subsidize everyone else's poor decisions
Breaking an ankle is not a "decision". Tuberculosis is not a "decision". Cancer is not a "decision". Alzheimer's is not a "decision". "Getting old" is not a "decision".
You're thinking about this backwards. Health is a personal responsibility. The things you cite are not decisions, naturally, but many things that make people sick are choices (smoking, poor diet, not exercising, etc) and the choice to not pursue employment that provides adequate health insurance is.
That's the deal with citizenship - we allow you to live with us as long as you pay for other people. In particular, paying for people that don't make good decisions for themselves. Which is fine, since everyone is poorer than someone else.
No one is interested in allowing you to live in a country without paying for it. You live under the permission of others.
Them's the rules - take it or leave it.
No one is interested in allowing you to live in a country without paying for it. You live under the permission of others.
Them's the rules - take it or leave it.
you allow me to? so what if I stop working and pay no taxes? do I have to leave? you sound very self righteous. I assume you're a typical liberal. do you realize you're making an argument against illegal immigration?
As a typical self-righteous liberal, I'll just say that: illegal immigrants pay taxes.
L'Etat c'est la grande fiction à travers laquelle tout le monde s'efforce de vivre aux dépens de tout le monde.
The State is the great fiction through which everyone endeavours to live at the expense of everyone else.
The State in Journal des débats (1848) par. 5.20.
https://en.wikiquote.org/wiki/Fr%C3%A9d%C3%A9ric_Bastiat#Quo...
You already subsidise healthcare.
The US government spends more per capita on health than the UK government does.
The US government spends more per capita on health than the UK government does.
Ok, well, as a cyclist who doesn't own a car, and as a vegetarian who doesn't eat meat, and as a childless infertile dude, I'm sure tired of subsidizing you cow-eating motorist parents.
Oh, wait, that's what society is--we all pay for communal stuff because we're all ultimately in this together.
Oh, wait, that's what society is--we all pay for communal stuff because we're all ultimately in this together.
It looks like you've been using HN primarily for political arguments. That's not what this site is intended for, so please don't do that.
> Oh, wait, that's what society is-
No, that's what socialism and communism are.
No, that's what socialism and communism are.
mcbruiser(1)
Yeah, I'm sure all the people who chose to get cancer or be born prematurely are just leeching off the rest of us. Even if you rarely ever use the system, you're still better off having a country where people don't have to worry about going bankrupt of something terrible happens to them and they need healthcare. Also, it actually makes things easier for businesses to not have to deal with figuring out how to pay for insurance for everyone every year.
A single tax that you can plan for without worry and just get on with running your company? Sounds good to me.
A single tax that you can plan for without worry and just get on with running your company? Sounds good to me.
> Yeah, I'm sure all the people who chose to get cancer or be born prematurely are just leeching
Please don't vent snark like this on HN, even when someone else is wrong and/or started it. Your comment would be just fine without that.
Please don't vent snark like this on HN, even when someone else is wrong and/or started it. Your comment would be just fine without that.
I wouldn't mind paying more taxes in order to provide others with something I consider a human right.
Under single-payer, CA employers will no longer need to provide insurance for their employees. That money could in some way pay for this. It also makes the idea of a 'gig economy' much more palatable, since people working in short-term / part-time situations will no longer have to go without employer-provided insurance. It could be a source of further economic growth since that makes CA a much more friendly place to start a business.
More centralized healthcare systems also have two arguments for driving down cost - one being that such a system is more effective at promoting timely / preventative care (which is a lot cheaper than emergency care). The second is that such a system can negotiate prices with providers more effectively, and invest in long-term projects to reduce the cost of care, driving down the cost of healthcare overall.
Under single-payer, CA employers will no longer need to provide insurance for their employees. That money could in some way pay for this. It also makes the idea of a 'gig economy' much more palatable, since people working in short-term / part-time situations will no longer have to go without employer-provided insurance. It could be a source of further economic growth since that makes CA a much more friendly place to start a business.
More centralized healthcare systems also have two arguments for driving down cost - one being that such a system is more effective at promoting timely / preventative care (which is a lot cheaper than emergency care). The second is that such a system can negotiate prices with providers more effectively, and invest in long-term projects to reduce the cost of care, driving down the cost of healthcare overall.
California is already running a budget deficit, in part because of the health subsidies it already provides. Also, it allows voluntary contributions, so you can already pay more taxes: https://www.ftb.ca.gov/individuals/vcfsr/vcf_faqs.shtml
Thus far I have been able to resist the tempation to do so.
Thus far I have been able to resist the tempation to do so.
> Also, it allows voluntary contributions, so you can already pay more taxes
That's for charitable contributions...
That's for charitable contributions...
If you don't specify a charity it goes into the general fund. It's mentioned somewhere in that page.
Yep. Trying to solve this at the state level is a nice idea (and it certainly needs to be solved!), but it's actually harder to solve than at the federal level because you get all the same issues plus a few new ones, plus you can't actually change some key rules that are set at the federal level.
If your proposed solution doesn't start with a plan to bring healthcare costs into line with the OECD average, then even if your plan works it's like trying to bail out a leaky boat by scooping water up and pouring it back into the boat.
This one...doesn't even try. Yes, if health care cost the same in the US as it did in Germany this plan would work great...but it doesn't. You can paint a Yugo red, but it doesn't magically turn into a Porsche.
(And before anyone asks...no, the best estimates of potential savings from switching to single payer is orders of magnitude too low. The NHS works because medical care is cheap to provide in the UK; medical care isn't cheap to provide in the UK because of the NHS.)
If your proposed solution doesn't start with a plan to bring healthcare costs into line with the OECD average, then even if your plan works it's like trying to bail out a leaky boat by scooping water up and pouring it back into the boat.
This one...doesn't even try. Yes, if health care cost the same in the US as it did in Germany this plan would work great...but it doesn't. You can paint a Yugo red, but it doesn't magically turn into a Porsche.
(And before anyone asks...no, the best estimates of potential savings from switching to single payer is orders of magnitude too low. The NHS works because medical care is cheap to provide in the UK; medical care isn't cheap to provide in the UK because of the NHS.)
In general this true, but California is unique among American states in that its got an economy and a population bigger than most other nations in the OECD.
That is to say, we've reached a scale where we absolutely can start thinking and acting like a nation state. That doesn't mean that smaller, poorer, and weaker states can simply copy what we do directly, one-by-one. But it does mean they can band together to see that a demonstrably good model gets implemented at the Federal level.
That is to say, we've reached a scale where we absolutely can start thinking and acting like a nation state. That doesn't mean that smaller, poorer, and weaker states can simply copy what we do directly, one-by-one. But it does mean they can band together to see that a demonstrably good model gets implemented at the Federal level.
I live in New Zealand, population 4 million. If scale alone was critical, then Aetna (which covers about 23 million people in the US) would be squeezing really good pricing deals out of their suppliers, while NZ would be seeing really high costs. Nothing could be further from the truth.
(This is true, incidentally, because in large part NZ's low costs come from just buying less stuff. Fewer fancy drugs, fewer fancy machines, smaller and older hospitals, and lower salaries for doctors and nurses. Works great, but this is politically infeasible in the US, to say the least, which is probably why California isn't even dreaming about trying it.)
Yes, California has 38 million people or whatever, but other large groups of in the US can't get good deals (be that insurers like Aetna or Kaiser, or government programs like Medicare). They're not larger than Medicare, so that's out. Are they going to be greedier that Aetna? Really? Or is the famously dysfunctional and lobbyist dominated government in Sacremento going to make some hard choices and piss off the voters?
> But it does mean they can band together to see that a demonstrably good model gets implemented at the Federal level.
I'm a very strong proponent of federalism and the states as laboratories of democracy and all that. But... What California is proposing to do is not really new or untested. It's an expansion of a system that already exists in the US, and closely replicates systems from other countries. Yes, it works great if costs are low, and will bankrupt the state if costs are high. Costs are currently high. How do you square that circle?
(This is true, incidentally, because in large part NZ's low costs come from just buying less stuff. Fewer fancy drugs, fewer fancy machines, smaller and older hospitals, and lower salaries for doctors and nurses. Works great, but this is politically infeasible in the US, to say the least, which is probably why California isn't even dreaming about trying it.)
Yes, California has 38 million people or whatever, but other large groups of in the US can't get good deals (be that insurers like Aetna or Kaiser, or government programs like Medicare). They're not larger than Medicare, so that's out. Are they going to be greedier that Aetna? Really? Or is the famously dysfunctional and lobbyist dominated government in Sacremento going to make some hard choices and piss off the voters?
> But it does mean they can band together to see that a demonstrably good model gets implemented at the Federal level.
I'm a very strong proponent of federalism and the states as laboratories of democracy and all that. But... What California is proposing to do is not really new or untested. It's an expansion of a system that already exists in the US, and closely replicates systems from other countries. Yes, it works great if costs are low, and will bankrupt the state if costs are high. Costs are currently high. How do you square that circle?
I'm sorry, but you've completely missed the point of a single-payer system. You don't set one up to get better deals out of insurance companies. Under single payer you put for-profit insurance companies out of business.
Hospitals and pharmaceutical companies then negotiate directly with the state. And as far as what they can be expected to accept without going out of business themselves goes, we can get a pretty good idea from the expenditures of every other OECD country.
Hospitals and pharmaceutical companies then negotiate directly with the state. And as far as what they can be expected to accept without going out of business themselves goes, we can get a pretty good idea from the expenditures of every other OECD country.
I'm very new to the single-payer idea, but Vermont rates 49th for population in the US, California ranks 1st. I thought one of the strengths of a single-payer system was to leverage the power of large numbers to help drive costs down. Would this not make it more viable?
We even know California's population is large enough to support its own single-payer system since Canada has a slightly smaller population and a single payer system.
The trick is whether the transition to a single payer system is feasible. Both in terms of taxes, and existing organizations and incentives.
The trick is whether the transition to a single payer system is feasible. Both in terms of taxes, and existing organizations and incentives.
"We even know California's population is large enough to support its own single-payer system since Canada has a slightly smaller population and a single payer system."
Except Canada can (for the most part) control who can enter, stay, and participate in the system, while California is at the mercy of its open borders (newcomers from other states or countries).
Except Canada can (for the most part) control who can enter, stay, and participate in the system, while California is at the mercy of its open borders (newcomers from other states or countries).
It's a bad idea to compare California to Canada or Australia, because even with our great economy we don't control our currency. Countries can deficit-spend but we have to actually pay for things.
This is the same flaw (see Strong Towns) that leads cities to tear down useful buildings and replace it with parking lots and highways, because the federal government gave them money to build them, but not to maintain them… so they go broke.
Huh, I just realized I'm wrong because California voters always approve state bond measures. We're safe after all.
This is the same flaw (see Strong Towns) that leads cities to tear down useful buildings and replace it with parking lots and highways, because the federal government gave them money to build them, but not to maintain them… so they go broke.
Huh, I just realized I'm wrong because California voters always approve state bond measures. We're safe after all.
Australia did it. It won't happen overnight, but the planning has to start somewhere.
Also: lots of doctors probably enjoy living in California, and couldn't easily move elsewhere, whereas Vermont is pretty small and one could pretty easily move to NH or upstate NY or somewhere else close by.
Vermont is one of the poorest states in the nation as well, while California's economy is one of the biggest in the world.
Vermont is 32nd in per capita GDP. Poorest would be Mississippi, dead last. California is indeed a massive economy and we're ranked 10th in per capita GDP.
https://en.wikipedia.org/wiki/List_of_U.S._states_by_GDP_per...
One point about our size. When CA does something at the state level a lot of other states follow along. Minnesota can't dictate to manufacturers but CA can.
https://en.wikipedia.org/wiki/List_of_U.S._states_by_GDP_per...
One point about our size. When CA does something at the state level a lot of other states follow along. Minnesota can't dictate to manufacturers but CA can.
That's GDP per capita. CA is the largest state in terms of overall GDP.
Overall population/economy size matters, not just per-capita.
Overall population/economy size matters, not just per-capita.
Per capita GDP matters more in determining whether Vermont or California can better afford this. In fact, CA can better afford this than Vermont.
By comparison, Mississippi cannot afford this. They're basically supported by states like California; their economy is trivial and they're propped up by defense spending.
By comparison, Mississippi cannot afford this. They're basically supported by states like California; their economy is trivial and they're propped up by defense spending.
Why? Disagree with your reasoning, it's not about per-capita, it's about absolute numbers in the risk pool and ability for a large actor like CA to better negotiate prices down.
Why do you think Apple gets better prices than, e.g. Logitech for component parts? Because they order massively more, up-front, and with strict timetables for delivery.
Why do you think Apple gets better prices than, e.g. Logitech for component parts? Because they order massively more, up-front, and with strict timetables for delivery.
Costs are still per capita. We will only be able to negotiate so much and we'd be negotiating with providers rather the insurance companies.
To be very clear, I think CA can afford this and I think we should do it.
To be very clear, I think CA can afford this and I think we should do it.
In what way is Vermont one of the poorest states?
There are a lot of very poor communities in Vermont, though I doubt Vermont is poor by median household income. I don't have the numbers in front of me but in terms of corporate tax base, Vermont is probably quite poor compared to NY or CA.
Ben and Jerry's can only foot so much of the tax bill.
Ben and Jerry's can only foot so much of the tax bill.
I have an common sense observation and questions. Apple, Microsoft etc you name it, all get their hardware products manufactured in china & Asian countries mainly to drive down costs (People blame CEOs but really ? do they have a choice ? Will wall street show mercy on them ? It is easy to forget that US consumers are the primary beneficiaries, and Wall street is happy - means - 401ks, IRAs of regular US citizens grow ! ). How come pharma companies dont follow that model and drive down the prices of drugs/medicines ? How come healthcare providers dont use "globalization" for cutting health care costs where apparently it matters the most ? One can live without iphones or electronics, but cant live without necessary medicines or proper healthcare. Without driving down drug prices or hospital costs, how can healthcare problem be solved, no matter what system is used ?
Mostly because the cost of drugs isn't dominated by manufacturing costs the way it is with electronics. The vast majority of the cost of a drug is in the development of it. Further, of the costs for developing it, the cost is split fairly evenly between paying for the skilled researchers who actually do the development, and the administrative costs of testing and certification. As for the actual production of the finished drug, that is off-shored for savings, but since most of the cost of the drug is actually going towards offsetting the massive piles of money poured into researching and developing not just that drug but to offset the costs of all the failed drugs, reducing the actual production cost barely moves the needle.
The above is of course talking about newly developed drugs. There is however a rather disturbing recent predatory practice some drug manufacturers have started to engage in of either purchasing an existing drug and jacking up the price if they're the sole manufacturer, or else making a trivial change to an existing drug and then re-releasing it at massively inflated price. In either case the effect is the same, they're selling a drug that has no appreciable research costs associated with it, just the manufacturing price, but they're continuing to charge as if they were having to offset the research costs and they get away with it because that's what people are used to.
The above is of course talking about newly developed drugs. There is however a rather disturbing recent predatory practice some drug manufacturers have started to engage in of either purchasing an existing drug and jacking up the price if they're the sole manufacturer, or else making a trivial change to an existing drug and then re-releasing it at massively inflated price. In either case the effect is the same, they're selling a drug that has no appreciable research costs associated with it, just the manufacturing price, but they're continuing to charge as if they were having to offset the research costs and they get away with it because that's what people are used to.
It's not a commodity good (in part bc of drug patents). An iPhone may cost more in Asia, but drug treatments are way cheaper. The comparison doesn't really work.
Your conflating cost based pricing and market based pricing.
None of the players above (including apple) engage in cost based pricing. They all charge the price that maximizes their profits, not the price that sells the most units while breaking even.
None of the players above (including apple) engage in cost based pricing. They all charge the price that maximizes their profits, not the price that sells the most units while breaking even.
The Affordable Care Act has a provision in it that allows states to apply for "waivers for state innovation"[1] starting this year. That waiver program might allow for this to receive federal funding.
That said, the future of the Affordable Care Act is currently unclear.
[1] https://en.wikipedia.org/wiki/Patient_Protection_and_Afforda...
That said, the future of the Affordable Care Act is currently unclear.
[1] https://en.wikipedia.org/wiki/Patient_Protection_and_Afforda...
Interesting tidbit from the 3rd article:
"Ultimately, Thornberg believes California would be better served with a Texas-style tax revenue system where there's less reliance on personal income taxes and capital gains tied to the stock market, and more of a focus on property taxes and sales taxes."
So long as high priced real-estate are exchanging hands, CA will reap the benefit.
"Ultimately, Thornberg believes California would be better served with a Texas-style tax revenue system where there's less reliance on personal income taxes and capital gains tied to the stock market, and more of a focus on property taxes and sales taxes."
So long as high priced real-estate are exchanging hands, CA will reap the benefit.
Real estate is expensive in CA precisely because of Prop 13.
In order to switch to a property tax revenue model you need to repeal Prop 13, at which point real estate prices and thus prospective revenue will plummet.
Prop 13 incentivizes homeowners to stay put until they die. In other words, it puts tremendous downward pressure on the housing supply which results in a self-reinforcing feedback loop whereby the more real estate prices grow the greater the tax incentive to stay put.
Changing this state of affairs is near impossible. Nobody is going to trade increased mobility and a more efficient housing market for a precipitous drop in the paper value of their primary asset, even though on the whole it'd probably be better for everybody.
Why precipitous? Because locking in, under Prop 13, your first year property valuation is a huge part of the calculus for determining affordability and your bidding price. If a new home owner doesn't get the benefit of Prop 13, he's going to pay far less for a house. Which means you can't even ease California out of the cycle by grandfathering existing homeowners in the hopes of avoiding their ire.
Repealing Prop 13 just isn't politically viable. It's a fascinating state of affairs.
Prop 13 incentivizes homeowners to stay put until they die. In other words, it puts tremendous downward pressure on the housing supply which results in a self-reinforcing feedback loop whereby the more real estate prices grow the greater the tax incentive to stay put.
Changing this state of affairs is near impossible. Nobody is going to trade increased mobility and a more efficient housing market for a precipitous drop in the paper value of their primary asset, even though on the whole it'd probably be better for everybody.
Why precipitous? Because locking in, under Prop 13, your first year property valuation is a huge part of the calculus for determining affordability and your bidding price. If a new home owner doesn't get the benefit of Prop 13, he's going to pay far less for a house. Which means you can't even ease California out of the cycle by grandfathering existing homeowners in the hopes of avoiding their ire.
Repealing Prop 13 just isn't politically viable. It's a fascinating state of affairs.
As I understand it, a big part of Vermont's problem was due to numbers. They had too small of a population.
California does not have that problem.
California does not have that problem.
California could get rid of their budget issues instantly with a progressive property tax. How about an extra bracket for nonhomesteads starting at values over $1M?
How about we get rid of Prop 13, a not-so-stealth tax on the young.
There are many bad things about Prop 13. Indeed I'm straining to think of anything good about it. But the worst is that it applies to commercial property as well.
> But the worst is that it applies to commercial property as well.
ding. Got it in one.
Normal residential properties transact roughly every 10-15 years with 40-50 years being on the way outside. So, most residential properties aren't too far behind their real value in taxes.
Commercial properties never transact; they just add more subleases. We had one property we rented which had 23 layers of sublease to avoid Prop 13.
ding. Got it in one.
Normal residential properties transact roughly every 10-15 years with 40-50 years being on the way outside. So, most residential properties aren't too far behind their real value in taxes.
Commercial properties never transact; they just add more subleases. We had one property we rented which had 23 layers of sublease to avoid Prop 13.
The Legislature is free to pass a Legislative Constitutional Amendment to remove part or all of Prop 13 protections (e.g. for commercial or rental property at least); all it would take is a simple majority of voters to take effect. They can even pick and choose which statewide election to use.
That requires an effort to repeal Prop 13 asap.
Maybe the time to begin such an initiative is now. And maybe the tech industry, which has long suffered from the related housing crisis, should back such an initiative.
It's financially feasible if everyone's contributing. So if it were done as a progressive tax, just like income tax, rather than making a portion of it employer paid while then exempting employers who operate in multiple state; in fact in today's world exempting companies that don't even do business in the state other than having employees in that state is a problem. There's also no integration with Medicaid or Medicare.
Anyway, there's no reason it's a financial funding problem. No matter what it's some kind of tax. Either it's a government tax for a government operated health care system (single payer); or it's a tax on the business vis a vis employer based insurance where they are the true customer not those who are insured; or it's a tax on the employee getting a plan on the market place if the employer doesn't provide one.
The number one problem is that it's simply too profitable for doctors, hospitals, clinics, and insurance companies right now, to have system that incentivizes pay per procedure per per visit, rather than paying for health. It is not health care, it's sick care. Very little of our system incentivizes health. A miniscule number of insurers pay if you actually show up at a gym, not merely pay for the gym; or pay you to lose weight by actually getting weighed at an approved clinic, and so on.
It's presently politically untenable that we have for-profit education to become a doctor, and salaried doctors.
And there probably isn't a way to make this work on a scale like Vermont. It's probably possible to do it on the scale of California, but deeply depends on the politics.
Democrats basically took a dump on ACA. They tried to get Republicans on board, which is why they went with the Heritage Foundation plan. But then Republicans didn't go for it anyway. So what they should have done, hindsight being 20/20, is offer Americans a way to buy into Medicare rather than set up all these stupid state exchanges to expand a busted for-profit system. Oh well!
Anyway, there's no reason it's a financial funding problem. No matter what it's some kind of tax. Either it's a government tax for a government operated health care system (single payer); or it's a tax on the business vis a vis employer based insurance where they are the true customer not those who are insured; or it's a tax on the employee getting a plan on the market place if the employer doesn't provide one.
The number one problem is that it's simply too profitable for doctors, hospitals, clinics, and insurance companies right now, to have system that incentivizes pay per procedure per per visit, rather than paying for health. It is not health care, it's sick care. Very little of our system incentivizes health. A miniscule number of insurers pay if you actually show up at a gym, not merely pay for the gym; or pay you to lose weight by actually getting weighed at an approved clinic, and so on.
It's presently politically untenable that we have for-profit education to become a doctor, and salaried doctors.
And there probably isn't a way to make this work on a scale like Vermont. It's probably possible to do it on the scale of California, but deeply depends on the politics.
Democrats basically took a dump on ACA. They tried to get Republicans on board, which is why they went with the Heritage Foundation plan. But then Republicans didn't go for it anyway. So what they should have done, hindsight being 20/20, is offer Americans a way to buy into Medicare rather than set up all these stupid state exchanges to expand a busted for-profit system. Oh well!
California legislature is much more financially reckless than Vermont's
The article you cite points at resistance to tax increases as the culprit. No state can afford single payer without a tax increase to fund it, so the talk of "budget issues" is misleading. It's simply a matter of convincing everyone to trade paying private insurers for a tax increase. Vermont got pushback from the business community saying it would hurt the economy, but that seems suspect to me considering they would not have to pay private premiums anymore. That and the economic benefits of a healthy population.
As [1] points out, overall costs are less with single payer healthcare. Taxes go up, but insurance premiums go down more and people end up paying less overall. It's a no brainer...
I'd rather pay for single payer than see $54B go to the military [1] or $20B for a pointless wall. And honestly, having a healthier populace would likely lower the overall cost over time. I don't think we spend enough effort on preventative care as opposed to treatment.
[1] This shows how crazy the current spend is already. https://i.redd.it/6srj4xgpmriy.png
[1] This shows how crazy the current spend is already. https://i.redd.it/6srj4xgpmriy.png
Because they didn't add provisions to control pharma and hospital gouging. Let them run free and they'll suck you dry.
[deleted]
> CA is already dealing with severe budget issues [2][3],
False. California has a budget surplus of nearly $3 billion and will be able to weather a mild recession without major budget cuts or tax increases for the next 4 years.
False. California has a budget surplus of nearly $3 billion and will be able to weather a mild recession without major budget cuts or tax increases for the next 4 years.
Jerry Brown says there is a projected 1.6 billion dollar deficit. Where did you get your numbers from?
http://www.latimes.com/politics/la-pol-sac-jerry-brown-budge...
http://www.latimes.com/politics/la-pol-sac-jerry-brown-budge...
The 2016-2017 fiscal year! year. Interesting, thanks for the correction
> it sounds nice in theory I'm hesitant to believe the finances actually work out.
Many places pull it off around the world, though at a national level. Probably few are as wealthy as California.
Many places pull it off around the world, though at a national level. Probably few are as wealthy as California.
It seems to be working pretty well in Canada.
Note that this bill, in its current form, has no substantive effect; it would only "make findings and declarations with regard to the availability and affordability of health care coverage and would state the intent of the Legislature to enact legislation that would establish a comprehensive universal single-payer health care coverage program and a health care cost control system for the benefit of all residents of the state."
The actual legislation establishing single-payer health coverage and a cost control system has not been proposed.
The actual legislation establishing single-payer health coverage and a cost control system has not been proposed.
Thanks, we added 'make findings' above. If someone suggests a better (more accurate and neutral) title we can change it again.
I'm excited to see this show up on hacker news.
As a Santa Monica resident, I'd gladly pay more in taxes for universal coverage. The only way that we are going to achieve federal universal coverage is via states paving the way. Just as "Romney care" was a predecessor to the ACA, so can healthy California pave the way for the US to join the rest of the modern world with guaranteed access.
As a Santa Monica resident, I'd gladly pay more in taxes for universal coverage. The only way that we are going to achieve federal universal coverage is via states paving the way. Just as "Romney care" was a predecessor to the ACA, so can healthy California pave the way for the US to join the rest of the modern world with guaranteed access.
How much more would you be glad to pay?
How much more would you be glad for your employer to pay on your behalf?
How do you define "universal coverage"?
How much more would you be glad for your employer to pay on your behalf?
How do you define "universal coverage"?
Just curious why you would gladly pay more? Can you elaborate?
Can't speak for the poster, but I live in the Bay Area, and also would happily pay more in taxes for this to happen.
That's because I think long-term, single-payer is the only sensible way to handle health care. We have (the US has) a truly screwed up healthcare system that (nearly) everyone acknowledges is inefficient, too expensive, wasteful and less effective than it could be. Looking at other countries, this is obvious.
Given the money involved, getting to single-payer will be a long-term project; now even longer, to clean up the mess currently being made. It'll involve more fighting, take longer, and be a more expensive transition than anyone likes.
Given all that, we have to start somewhere. I'm happy to start in my state, even though I have great (employer-provided) healthcare, and could easily pay for my own if I didn't.
There's also the aspect of doing the right thing, even at personal cost. I think single-payer is the right thing to do.
So that's why.
That's because I think long-term, single-payer is the only sensible way to handle health care. We have (the US has) a truly screwed up healthcare system that (nearly) everyone acknowledges is inefficient, too expensive, wasteful and less effective than it could be. Looking at other countries, this is obvious.
Given the money involved, getting to single-payer will be a long-term project; now even longer, to clean up the mess currently being made. It'll involve more fighting, take longer, and be a more expensive transition than anyone likes.
Given all that, we have to start somewhere. I'm happy to start in my state, even though I have great (employer-provided) healthcare, and could easily pay for my own if I didn't.
There's also the aspect of doing the right thing, even at personal cost. I think single-payer is the right thing to do.
So that's why.
It's certainly better than the current way, but single payer is not the only way. Look at Germany for example, where the government sets minimum coverage and the premium (in a band as a % of the salary which the state will pay if you don't earn enough), but coverage is then provided by not-for-profit entities. This allows some competition by eliminating inefficient providers while making sure that everyone receives the same treatment.
I think such a system would work much better for the US as it's easier for the state to build such a framework than to come up with health care for everyone. The NHS (UKs single payer health provider) is the biggest employer in the state, which gives you some indication on how complex it is to provide universal healthcare for everyone.
I think such a system would work much better for the US as it's easier for the state to build such a framework than to come up with health care for everyone. The NHS (UKs single payer health provider) is the biggest employer in the state, which gives you some indication on how complex it is to provide universal healthcare for everyone.
Just agreeing with what others have said: I'd prefer not to live in a world where bad luck means easily avoidable pain and suffering, or where many people live in semi-constant fear that a malicious or incompetent company will prevent them from getting vital care or create an acute financial crisis.
If you only care about yourself, ask what would happen if you developed a serious illness or were in a bad accident: very few people have the millions of dollars needed to survive something like that and you have no way to know if that's going to happen or avoid it even if you did.
I'd say I'd gladly pay more in taxes not to have to worry about that except that the experience of every other developed nation suggests it'd be a massive price reduction.
If you only care about yourself, ask what would happen if you developed a serious illness or were in a bad accident: very few people have the millions of dollars needed to survive something like that and you have no way to know if that's going to happen or avoid it even if you did.
I'd say I'd gladly pay more in taxes not to have to worry about that except that the experience of every other developed nation suggests it'd be a massive price reduction.
OK, so when this is rolled out and healthcare costs don't come down, but rather increase at the same rate, will you be happy to pay another 10-20% in taxes knowing the problem isn't solved?
There are many reasons. On a personal level, I believe high income people (like us tech folk) SHOULD help take care of less financially fortunate groups of people.
Practically speaking, worrying about health care (and the lack thereof) is the number one reason that makes it hard to start your own company...unless you are already wealthy.
Practically speaking, worrying about health care (and the lack thereof) is the number one reason that makes it hard to start your own company...unless you are already wealthy.
I'm not OP, but I'll answer. I care about my fellow human beings. I make more than most. I want them to have health care. I am willing to pay more taxes into a system that covers everyone so they can all have health care. I could go around and throw a few dollars into every GoFundMe for healthcare that I come across, but in the end it is more efficient to have everyone under the same system driving costs down than it is for people to have to beg and plead for charity to help cover their medical bills.
Not me, but I can tell you why I would pay more taxes.
For one, having health care tied to a job is a big burden. As an employee, it makes choosing to leave my job extremely worrisome, especially if the federal government repeals the pre-existing conditions portion of the ACA. I can never leave my job while I am sick, or my kids are sick.
Tying your health care to work also makes it harder to start a small business. You need to offer your employees health care to compete for good workers, but it costs a lot more per employee for a small company to get insurance than for a big company (a big company can get a better deal because they have a larger cohort).
An even more insidious fact of employer based health care is that it doesn't cost the same for everyone. If I am going to hire someone and offer health care, it will be MUCH more expensive for an employer if the person is going to have their children and/or spouse covered as well. It will cost more if they are older. It will cost more if they have medical conditions.
This adds a perverse incentive to employers to favor hiring younger, single, people. As an employer, I should not be worried about the marital and familial status of my employee. I should pay them the salary we agree to. There are laws against discriminating against some of these groups, but if you are a small company it makes a huge difference to your bottom line.
I also fear getting a major illness. Suppose I am doing everything right, working and I have health insurance. I get cancer, and it is treatable, but it might take years to beat. I start out fine, with my good insurance. One year in, it becomes clear I can't keep working my job, so I am let go. I can keep paying for my own insurance through COBRA, but my savings are dwindling because I am no longer working. Even if I am suddenly able to work again, I wouldn't be able to get new insurance because of my pre-existing condition.
There is literally NO amount of planning I could have done to avoid this situation. I was doing everything right, and an illness can make you go bankrupt.
The last argument for why I would pay more for health insurance is a moral one. I find it immoral to not provide basic health care to everyone. I feel it is an obligation we have to each other, and the most efficient way to meet that obligation is through a single payer system. Insurance works best with the largest possible pool of people to spread the risk, and you can't get a larger pool than everyone.
So yes, I am willing to pay a little more for a single payer system, for both selfish and altruistic reasons.
For one, having health care tied to a job is a big burden. As an employee, it makes choosing to leave my job extremely worrisome, especially if the federal government repeals the pre-existing conditions portion of the ACA. I can never leave my job while I am sick, or my kids are sick.
Tying your health care to work also makes it harder to start a small business. You need to offer your employees health care to compete for good workers, but it costs a lot more per employee for a small company to get insurance than for a big company (a big company can get a better deal because they have a larger cohort).
An even more insidious fact of employer based health care is that it doesn't cost the same for everyone. If I am going to hire someone and offer health care, it will be MUCH more expensive for an employer if the person is going to have their children and/or spouse covered as well. It will cost more if they are older. It will cost more if they have medical conditions.
This adds a perverse incentive to employers to favor hiring younger, single, people. As an employer, I should not be worried about the marital and familial status of my employee. I should pay them the salary we agree to. There are laws against discriminating against some of these groups, but if you are a small company it makes a huge difference to your bottom line.
I also fear getting a major illness. Suppose I am doing everything right, working and I have health insurance. I get cancer, and it is treatable, but it might take years to beat. I start out fine, with my good insurance. One year in, it becomes clear I can't keep working my job, so I am let go. I can keep paying for my own insurance through COBRA, but my savings are dwindling because I am no longer working. Even if I am suddenly able to work again, I wouldn't be able to get new insurance because of my pre-existing condition.
There is literally NO amount of planning I could have done to avoid this situation. I was doing everything right, and an illness can make you go bankrupt.
The last argument for why I would pay more for health insurance is a moral one. I find it immoral to not provide basic health care to everyone. I feel it is an obligation we have to each other, and the most efficient way to meet that obligation is through a single payer system. Insurance works best with the largest possible pool of people to spread the risk, and you can't get a larger pool than everyone.
So yes, I am willing to pay a little more for a single payer system, for both selfish and altruistic reasons.
It's generally just good for the entire community with benefits felt in a myriad of other issues, like gun violence, suicides, abortions, mental health, crime, drug and alcohol abuse, homelessness etc...
The question is, why wouldn't a society or community want universal healthcare for it's people?
The question is, why wouldn't a society or community want universal healthcare for it's people?
Because I don't want my friends and family and neighbors to suffer and die
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Glad you have that luxury, CA has some of the highest taxes anywhere and I would definitely be opposed to more.
um, not really. the property taxes are so broken that many people own multi-million dollar homes and pay for them as if they were worth nearly nothing. that said, sales tax and state tax rates are high, so if you just mean that, you are right.
>> that said, sales tax and state tax rates are high, so if you just mean that, you are right.
This is a result of the property taxes being fixed(ish) though, isnt it? Since they cant get true value from that, they have to raise other taxes to make up for it.
This is a result of the property taxes being fixed(ish) though, isnt it? Since they cant get true value from that, they have to raise other taxes to make up for it.
https://taxfoundation.org/state-and-local-sales-tax-rates-20...
“The five states with the highest average combined state and local sales tax rates are Tennessee (9.46 percent), Arkansas (9.30 percent), Louisiana (9.0 percent), Alabama (8.97 percent), and Washington (8.90 percent).”
“The five states with the highest average combined state and local sales tax rates are Tennessee (9.46 percent), Arkansas (9.30 percent), Louisiana (9.0 percent), Alabama (8.97 percent), and Washington (8.90 percent).”
That analysis ignores the income brackets.
If I have the choice of living where the state income tax hit 8% at $50K vs. %9 at $200K, I'd gladly live in the state with the "higher" state income tax rate.
If I have the choice of living where the state income tax hit 8% at $50K vs. %9 at $200K, I'd gladly live in the state with the "higher" state income tax rate.
That wasn't the question, however, any more than the far more important question of what you get for those taxes.
Most Californians live in areas with sales surtaxes, ending up at as much as 9.75%:
http://www.boe.ca.gov/app/rates.aspx?LETTER=S&LIST=CITY
http://www.boe.ca.gov/app/rates.aspx?LETTER=S&LIST=CITY
Tennessee has no income tax, so I'll gladly take 9.46% sales tax and no income tax over California's 8.48% sales tax plus 1% - 13.3% income tax.
You're free to leave anytime. Why haven't you? If you have, then your opinion is moot.
A single payer system is a step in the right direction, however, there are deeper issues with the American healthcare system.
The unit cost of healthcare is so much higher than in other developed countries.
In British Columbia, physicians bill at total of around $31 CAD ($23 USD) for a standard office visit. They pay all their overhead out of this fee. Typically doctors keep 65% of their billings and the offices take 35% for overhead. From what I can tell, a similar visit in Washington State will run between $60 and $200 USD when billed to insurance.
Why is this the case? What are the factors in the American system that prevent reasonable pricing?
http://www2.gov.bc.ca/assets/gov/health/practitioner-pro/med...
The unit cost of healthcare is so much higher than in other developed countries.
In British Columbia, physicians bill at total of around $31 CAD ($23 USD) for a standard office visit. They pay all their overhead out of this fee. Typically doctors keep 65% of their billings and the offices take 35% for overhead. From what I can tell, a similar visit in Washington State will run between $60 and $200 USD when billed to insurance.
Why is this the case? What are the factors in the American system that prevent reasonable pricing?
http://www2.gov.bc.ca/assets/gov/health/practitioner-pro/med...
It's the insurance companies dance with the healthcare providers. Over many decades, the insurance companies have negotiated payments much less than the quoted payment. In turn, the healthcare providers raise their rates in order to make sure they can still make money even with the discount they give insurance. When the time comes for the insurance companies to renegotiate, the same thing happens, and the healthcare providers raise their rates. This works fine for those of us who have insurance, but for non insured individuals, they have to pay the "actual" rate - which has been inflated because of the insurance company discount! This has been going on for many decades.
> ver many decades, the insurance companies have negotiated payments much less than the quoted payment. In turn, the healthcare providers raise their rates in order to make sure they can still make money even with the discount they give insurance. When the time comes for the insurance companies to renegotiate, the same thing happens, and the healthcare providers raise their rates. This works fine for those of us who have insurance, but for non insured individuals, they have to pay the "actual" rate - which has been inflated because of the insurance company discount! This has been going on for many decades
This is close to correct, but a subtle correction:
Medicare and Medicaid set their reimbursement rates by fiat, and providers have essentially no ability to negotiate those. Except in critical access areas, Medicare actually reimburses much less than the marginal costs of care for its patients (7% in the aggregate). As a result, providers present very large bills to everyone else (privately insured and uninsured patients) to make up for this loss - you can't stay in business if you're literally making a loss on every patient! Uninsured patients see the large bill and assume they have to pay the entire amount (they don't!), and private insurers end up negotiating that down to some multiple of what Medicare pays.
A typical insurer will negotiate an agreement like, "we'll pay 350% of what Medicare pays for this category of services".
This is close to correct, but a subtle correction:
Medicare and Medicaid set their reimbursement rates by fiat, and providers have essentially no ability to negotiate those. Except in critical access areas, Medicare actually reimburses much less than the marginal costs of care for its patients (7% in the aggregate). As a result, providers present very large bills to everyone else (privately insured and uninsured patients) to make up for this loss - you can't stay in business if you're literally making a loss on every patient! Uninsured patients see the large bill and assume they have to pay the entire amount (they don't!), and private insurers end up negotiating that down to some multiple of what Medicare pays.
A typical insurer will negotiate an agreement like, "we'll pay 350% of what Medicare pays for this category of services".
Great insights - never considered this.
I can't imagine that insurance not being available for purchase across state lines is helping here, either.
I can't imagine that insurance not being available for purchase across state lines is helping here, either.
It's really ridiculous, too. I went to the ER for stomach pains in california for 3 hours (ct scan, IV, and morphine). It was $3500 (no healthcare). I was in college and talked to them and paid around $800. I went to the ER in Japan overnight (12 hours) ct scan, IV, and it was $40 (insurance covered 70% so it was about $130).
There are several states where health insurance sells across state lines. It does not lower the price of health insurance.
How can you say that? When an arbitrary law creates artificial markets and restricts the choices of consumers, you really think that prices aren't affected?
Because health insurance is not about scarcity or moving goods across state lines. Setting up insurance is much more complex than that and I think that is why people get caught up in thinking that allowing insurance to be sold across state lines will help.
When an insurance company sets up in another state, they have create a network of doctors, hospitals and medical providers. The doctor network does not just pop up over night.
When an insurance company sets up in another state, they have create a network of doctors, hospitals and medical providers. The doctor network does not just pop up over night.
What are the factors? Number one is that doctors in the US are paid too much. Why is this? Because health insurance is purchased by employers, not individuals, so most people don't see or care how much it costs. This also explains number two - the price gouging by pharmaceutical companies and hospitals.
People will try to say it's because of malpractice insurance or because the US invents all the drugs (they don't) and bla bla and while those are contributing factors, it's very clear to me as a UK expat that key players in the medical system here just take too much money off people.
A simple example is that Paracetemol (Tylenol), available since the 1950s costs about 10x as much in my local CVS as it would in an equivalent British pharmacy (Boots). Why? Because the US market is already used to paying far too much so they have no idea what a rip off is.
People will try to say it's because of malpractice insurance or because the US invents all the drugs (they don't) and bla bla and while those are contributing factors, it's very clear to me as a UK expat that key players in the medical system here just take too much money off people.
A simple example is that Paracetemol (Tylenol), available since the 1950s costs about 10x as much in my local CVS as it would in an equivalent British pharmacy (Boots). Why? Because the US market is already used to paying far too much so they have no idea what a rip off is.
Mostly agree but I think you misrepresent this argument:
>People will try to say it's because of malpractice insurance or because the US invents all the drugs (they don't)
It's not that the US invents all the drugs, but that US customers bear a disproportionate share of the drug development costs because drug makers (whichever country they originate in) can actually charge above marginal price in the US, compared to the monopsonist discount that other countries can secure.
>People will try to say it's because of malpractice insurance or because the US invents all the drugs (they don't)
It's not that the US invents all the drugs, but that US customers bear a disproportionate share of the drug development costs because drug makers (whichever country they originate in) can actually charge above marginal price in the US, compared to the monopsonist discount that other countries can secure.
For one, doctors educational costs are astronomical in the U.S compared to other countries. The amount of people able to become doctors is artificially limited. Drug prices are unregulated. The cost of developing drugs is high and has been getting higher.
Hospitals have little price transparency and the cost of same procedures at different hospitals is wildly different. The same bag of saline can cost 10x more at one hospital vs another. In markets where there is price transparency, like Lasik surgery or other elective procedures, the prices are far more sane.
One thing that spending double as a percent of GDP on health care and getting worse outcomes proves is that THE SOLUTION TO THE PROBLEM IS NOT TO SPEND MORE MONEY. Unfortunately, this is the only thing American politics knows how to do as more money means more money for every special interest with their hand out.
Hospitals have little price transparency and the cost of same procedures at different hospitals is wildly different. The same bag of saline can cost 10x more at one hospital vs another. In markets where there is price transparency, like Lasik surgery or other elective procedures, the prices are far more sane.
One thing that spending double as a percent of GDP on health care and getting worse outcomes proves is that THE SOLUTION TO THE PROBLEM IS NOT TO SPEND MORE MONEY. Unfortunately, this is the only thing American politics knows how to do as more money means more money for every special interest with their hand out.
> The amount of people able to become doctors is artificially limited.
It is not artificially limited, and this is a common misconception that simply won't go away.
The bottleneck is currently the number of people who can complete residency training. Residency programs are not self-sufficient, so most of them are funded by Medicare. That's not an artificial limit - that's a natural one (the sheer economics of the process).
It is not artificially limited, and this is a common misconception that simply won't go away.
The bottleneck is currently the number of people who can complete residency training. Residency programs are not self-sufficient, so most of them are funded by Medicare. That's not an artificial limit - that's a natural one (the sheer economics of the process).
And (per previous discussion [1]) that doesn't explain it. If there is still excess demand for MD degrees, then there is still room for potential MDs to borrow any shortfall that residency subsidies won't cover.
The argument is like saying that Hamilton showings are limited by how much the government will pay in subsidies for the tickets. No. The demand is enough to cover expansion.
And even if it weren't there's still the issue of how much training is actually required to fill the functional role of a doctor. I'm pretty sure that there's some fat to cut out when you're making someone go all the way through a bachelors before they can even start.
[1] https://news.ycombinator.com/item?id=13593944
The argument is like saying that Hamilton showings are limited by how much the government will pay in subsidies for the tickets. No. The demand is enough to cover expansion.
And even if it weren't there's still the issue of how much training is actually required to fill the functional role of a doctor. I'm pretty sure that there's some fat to cut out when you're making someone go all the way through a bachelors before they can even start.
[1] https://news.ycombinator.com/item?id=13593944
> If there is still excess demand for MD degrees, then there is still room for potential MDs to borrow any shortfall that residency subsidies won't cover.
Because the amount of loan debt physicians have to take on is already massive, and very few want to increase that by an additional $112,000 (which is the amount Medicare provides). There are some, but empirically, not many.
The term of that loan is comparable to many mortgages, and there's enough uncertainty at this point in the expected payout that many qualified would-be doctors are incentivized to choose other professions instead, where they can make a pretty good living (and, possibly, a better one) much sooner and without the risk of taking out an additional series of six-figure loans on top of whatever may be outstanding from undergraduate education.
> The argument is like saying that Hamilton showings are limited by how much the government will subsidize ticket prices by.
Broadway ticket prices are a really bad analogy, because prices are intentionally sold below market-clearing rate for a whole slew of reasons that aren't directly comparable to the medical profession.
Because the amount of loan debt physicians have to take on is already massive, and very few want to increase that by an additional $112,000 (which is the amount Medicare provides). There are some, but empirically, not many.
The term of that loan is comparable to many mortgages, and there's enough uncertainty at this point in the expected payout that many qualified would-be doctors are incentivized to choose other professions instead, where they can make a pretty good living (and, possibly, a better one) much sooner and without the risk of taking out an additional series of six-figure loans on top of whatever may be outstanding from undergraduate education.
> The argument is like saying that Hamilton showings are limited by how much the government will subsidize ticket prices by.
Broadway ticket prices are a really bad analogy, because prices are intentionally sold below market-clearing rate for a whole slew of reasons that aren't directly comparable to the medical profession.
>Because the amount of loan debt physicians have to take on is already massive, and very few would want to increase that by an additional $112,000 (which is the amount Medicare provides).
Sure, you think it's expensive, but the demand is still there, people are willing to work for (net of costs) less than they currently are. That supports the claim that the service is priced above the market clearing level. (Edit: and they wouldn't be increasing debt by that full $112k; they could simply provide 80% of the existing subsidy per slot instead of the current 100%.)
>Broadway ticket prices are a really bad analogy, because prices are intentionally sold below market-clearing rate for a whole slew of reasons that aren't directly comparable to the medical profession.
No, that makes it a better analogy, because it's a case of good sold below it's market clearing price but which has excess demand capable of paying a (much) higher MCP, and where it's more obvious that the bottleneck isn't (and can't be) insufficient subsidies.
Sure, you think it's expensive, but the demand is still there, people are willing to work for (net of costs) less than they currently are. That supports the claim that the service is priced above the market clearing level. (Edit: and they wouldn't be increasing debt by that full $112k; they could simply provide 80% of the existing subsidy per slot instead of the current 100%.)
>Broadway ticket prices are a really bad analogy, because prices are intentionally sold below market-clearing rate for a whole slew of reasons that aren't directly comparable to the medical profession.
No, that makes it a better analogy, because it's a case of good sold below it's market clearing price but which has excess demand capable of paying a (much) higher MCP, and where it's more obvious that the bottleneck isn't (and can't be) insufficient subsidies.
> Sure, you think it's expensive, but the demand is still there, people are willing to work for (net of costs) less than they currently are. That supports the claim that the service is priced above the market clearing level.
* There are more people who apply for publicly-funded GME every year than there are positions available, yes.
* However, almost nobody (roughly speaking) applies for self-funded residency positions (which do exist).
I don't know how those two facts combine to say that "the demand is there" - there is not excess demand at market-clearing rates. There is only excess demand at a subsidized rate. People are not willing to work for less than they currently are; the supply is highly substitutable, and we're already seeing the effects of that.
* There are more people who apply for publicly-funded GME every year than there are positions available, yes.
* However, almost nobody (roughly speaking) applies for self-funded residency positions (which do exist).
I don't know how those two facts combine to say that "the demand is there" - there is not excess demand at market-clearing rates. There is only excess demand at a subsidized rate. People are not willing to work for less than they currently are; the supply is highly substitutable, and we're already seeing the effects of that.
I added an edit that there is plenty of room between full current subsidy and 0% subsidy.
You're doubling down on the strawman of adding new slots at 0% subsidy, and you're not considering the possibility that the requirements are too stringent to begin with. (Full bachelor's plus MD plus full residency.)
Edit: Also, it wouldn't be "seeing the effects" of it until the number of med school applications = number of med school slots.
You're doubling down on the strawman of adding new slots at 0% subsidy, and you're not considering the possibility that the requirements are too stringent to begin with. (Full bachelor's plus MD plus full residency.)
Edit: Also, it wouldn't be "seeing the effects" of it until the number of med school applications = number of med school slots.
There is no "full current subsidy" - the existing contributions from Medicare are already a partial subsidy.
But this is kind of a meaningless debate after a point, because the number of unmatched residents is already an upper bound on the number of additional matches (you certainly wouldn't have more people interested when you increased the price to them). And even then, we wouldn't see a huge difference - the number of unmatched domestic applicants isn't enough to make a meaningful dent in the labor supply of practicing physicians - and that's assuming all of the unmatched doctors are as properly qualified as their matched counterparts.
In other words, no, we're not at the exact market-clearing rates for the medical education market, and we consistently bias in one direction from that equilibrium, but we're measurably not far off from it.
But this is kind of a meaningless debate after a point, because the number of unmatched residents is already an upper bound on the number of additional matches (you certainly wouldn't have more people interested when you increased the price to them). And even then, we wouldn't see a huge difference - the number of unmatched domestic applicants isn't enough to make a meaningful dent in the labor supply of practicing physicians - and that's assuming all of the unmatched doctors are as properly qualified as their matched counterparts.
In other words, no, we're not at the exact market-clearing rates for the medical education market, and we consistently bias in one direction from that equilibrium, but we're measurably not far off from it.
>There is no "full current subsidy" - the existing contributions from Medicare are already a partial subsidy.
In the context, I meant "100% of current level"; I didn't mean to imply that it was "full" in that sense (and my point didn't depend on such).
>t this is kind of a meaningless debate after a point, because the number of unmatched residents is already an upper bound on the number of additional matches (you certainly wouldn't have more people interested when you increased the price to them)
You wouldn't have enough doctors if residents had to bear $1 extra in costs? That is implausible.
With respect, this exchange does not feel productive.
In the context, I meant "100% of current level"; I didn't mean to imply that it was "full" in that sense (and my point didn't depend on such).
>t this is kind of a meaningless debate after a point, because the number of unmatched residents is already an upper bound on the number of additional matches (you certainly wouldn't have more people interested when you increased the price to them)
You wouldn't have enough doctors if residents had to bear $1 extra in costs? That is implausible.
With respect, this exchange does not feel productive.
>Drug prices are unregulated. The cost of developing drugs is high and has been getting higher.
What do drug prices have to do with the cost of an office consultation?
What do drug prices have to do with the cost of an office consultation?
>> For one, doctors educational costs are astronomical in the U.S compared to other countries.
Doesn't this apply to all US educational costs (at the college level)? On the other hand doctors in the US seem to get paid a lot more than in, say, the UK.
Doesn't this apply to all US educational costs (at the college level)? On the other hand doctors in the US seem to get paid a lot more than in, say, the UK.
Insurance companies acting as profit-seeking middlemen between doctors and patients create a perverse incentive to drive up costs on both ends. It's a terrible feedback loop caused by treating health care (which is ultimately a cost center) as a for-profit enterprise. Every other modern country has managed to figure this out except the United States.
* It's a terrible feedback loop caused by treating health care (which is ultimately a cost center) as a for-profit enterprise.*
Ummm... you do realize that many other countries with universal coverage rely on private insurance, right?
Ummm... you do realize that many other countries with universal coverage rely on private insurance, right?
Not really the same thing. Insurers in a purely for-profit marketplace will always be incentivized to reject coverage for people with pre-existing conditions and drop coverage for people who become sick, because both groups are unprofitable to treat. The only way to avoid this is with strict regulations preventing insurers from doing what's in their own best interests at the expense of everyone else.
Why is single payer better? Genuinely curious. I just don't have any solid proof of the American Government doing a better job than the private industry enabled by competition.
It's hard to quantify 'better' but there are some major advantages to a single payer systems in terms of efficiencies. For example, a single standard for billing is in itself a major win.
Contracts and practice plans are considerably simplified ;-)
One problem is that "private industry enabled by competition" is not really an option. Deregulating healthcare would be close to impossible politically.
assuming you're asking in good faith, the answer is pretty simple. A larger population has more leverage, and if all of the citizens bargain as one bloc (i.e., if the government does so on their behalf), it drives the market. Note that a tremendous chunk of the market needs to be involved for this to have maximum effect -- if a physician can "opt out" of Medicare/MediCal and make more money, they will, by and large. (There's a reason that being on call instead of waiting for referrals is called "service")
Most physicians in (e.g.) the UK do participate in the single-payer market (there are a small number who make a living offering pay-as-you-go services, but they are the vanishing minority), since it dominates demand. In the US there are a great many physicians who simply won't accept Medicare rates (they're viewed as too low by most) and since there are alternative sources of patients, that's who they treat (typically privately insured). This leads to the cases that show up at County or the ER being a hell of a lot more expensive than necessary as they tend not to be survivable for long. (A running joke at most county hospitals is that conditions believed "incompatible with life" routinely walk or roll into the ER and clinics.)
If you have 1-3 insurance companies and MediCal/Medicaid and Medicare then you have different rates for different groups, almost all of it horrendously opaque, and the 3rd party insurers are not incentivized to pay for anything.
As far as private vs. public, the issue here is the same as for schools, a private insurer or school can choose not to insure or educate a "customer", the government by law cannot. In the handful of cross-over studies of charter schools or vouchers, after controlling for subject-specific effects, the children who switched from public to charter or private tended to do slightly worse than expected based on their test scores from public schools. (It is a difficult experiment to run for numerous reasons.)
Medical care, unlike most goods and services, is stunningly inelastic in demand -- you either need it and will do whatever is required to get it, or you don't and won't, by and large. (Elective surgeries for cosmetic purposes are a separate matter; nobody goes in for a stent "just because" or visits the trauma unit just to poke their head in) Furthermore, a substantial amount of the cost is centered on the first and last few years of a person's life. Unless you would like the "market driven solution" of even higher infant mortality and elderly culling to proceed, 3rd party insurers don't have the incentives to make it go.
Most physicians in (e.g.) the UK do participate in the single-payer market (there are a small number who make a living offering pay-as-you-go services, but they are the vanishing minority), since it dominates demand. In the US there are a great many physicians who simply won't accept Medicare rates (they're viewed as too low by most) and since there are alternative sources of patients, that's who they treat (typically privately insured). This leads to the cases that show up at County or the ER being a hell of a lot more expensive than necessary as they tend not to be survivable for long. (A running joke at most county hospitals is that conditions believed "incompatible with life" routinely walk or roll into the ER and clinics.)
If you have 1-3 insurance companies and MediCal/Medicaid and Medicare then you have different rates for different groups, almost all of it horrendously opaque, and the 3rd party insurers are not incentivized to pay for anything.
As far as private vs. public, the issue here is the same as for schools, a private insurer or school can choose not to insure or educate a "customer", the government by law cannot. In the handful of cross-over studies of charter schools or vouchers, after controlling for subject-specific effects, the children who switched from public to charter or private tended to do slightly worse than expected based on their test scores from public schools. (It is a difficult experiment to run for numerous reasons.)
Medical care, unlike most goods and services, is stunningly inelastic in demand -- you either need it and will do whatever is required to get it, or you don't and won't, by and large. (Elective surgeries for cosmetic purposes are a separate matter; nobody goes in for a stent "just because" or visits the trauma unit just to poke their head in) Furthermore, a substantial amount of the cost is centered on the first and last few years of a person's life. Unless you would like the "market driven solution" of even higher infant mortality and elderly culling to proceed, 3rd party insurers don't have the incentives to make it go.
> In the US there are a great many physicians who simply won't accept Medicare rates (they're viewed as too low by most)
Right there is the big problem, though: Medicare reimbursement rates are already below sustainable levels for providers, which actually results in providers charging private insurers for the difference.
If Medicare were expanded to everyone, either Medicare would have to increase its reimbursement rates, or you'd see providers close up their practices (which is already happening, and which is one of the current problems with providing affordable care outside urban areas).
> Medical care, unlike most goods and services, is stunningly inelastic in demand
That's actually not true at all - medical care is highly elastic, as evidenced by the utilization differences for people who have plans with high copays and deductibles compared to those who don't.
> As far as private vs. public, the issue here is the same as for schools, a private insurer or school can choose not to insure or educate a "customer", the government by law cannot. In the handful of cross-over studies of charter schools or vouchers, after controlling for subject-specific effects, the children who switched from public to charter or private tended to do slightly worse than expected based on their test scores from public schools. (It is a difficult experiment to run for numerous reasons.)
But we actually do have a point of comparison here, because Medicare does have both privately managed and publicly-managed plans (as does Medicaid). Consistently, the privately-managed plans come in under budget while delivering superior medical outcome metrics and patient satisfaction scores compared to Original Medicare (or the publicly-administered Medicaid plans).
Right there is the big problem, though: Medicare reimbursement rates are already below sustainable levels for providers, which actually results in providers charging private insurers for the difference.
If Medicare were expanded to everyone, either Medicare would have to increase its reimbursement rates, or you'd see providers close up their practices (which is already happening, and which is one of the current problems with providing affordable care outside urban areas).
> Medical care, unlike most goods and services, is stunningly inelastic in demand
That's actually not true at all - medical care is highly elastic, as evidenced by the utilization differences for people who have plans with high copays and deductibles compared to those who don't.
> As far as private vs. public, the issue here is the same as for schools, a private insurer or school can choose not to insure or educate a "customer", the government by law cannot. In the handful of cross-over studies of charter schools or vouchers, after controlling for subject-specific effects, the children who switched from public to charter or private tended to do slightly worse than expected based on their test scores from public schools. (It is a difficult experiment to run for numerous reasons.)
But we actually do have a point of comparison here, because Medicare does have both privately managed and publicly-managed plans (as does Medicaid). Consistently, the privately-managed plans come in under budget while delivering superior medical outcome metrics and patient satisfaction scores compared to Original Medicare (or the publicly-administered Medicaid plans).
Medicare reimbursement rates aren't necessarily too low if healthcare providers are currently overcharging. They could be perfectly be fair.
But as long as healthcare providers can find someone else to overcharge then they'll do that rather than accepting Medicare patients.
But as long as healthcare providers can find someone else to overcharge then they'll do that rather than accepting Medicare patients.
> Medicare reimbursement rates aren't necessarily too low if healthcare providers are currently overcharging. They could be perfectly be fair.
No, Medicare reimbursement rates are about 7% lower (in the aggregate, not individually) than COGS - the marginal costs of providing care. That is, if a test costs a provider $100 to purchase wholesale, Medicare reimburses $93, which doesn't cover the cost of the supplies, let alone covering overhead (wages for staff, office rent, etc.)
No, Medicare reimbursement rates are about 7% lower (in the aggregate, not individually) than COGS - the marginal costs of providing care. That is, if a test costs a provider $100 to purchase wholesale, Medicare reimburses $93, which doesn't cover the cost of the supplies, let alone covering overhead (wages for staff, office rent, etc.)
If that's true, why does any single doctor in the entire country take Medicare patients then?
> If that's true, why does any single doctor in the entire country take Medicare patients then?
Well, independent private practices have been dying out for precisely this reason, and outside of Critical Access regions (which have a higher fee structure), many don't anymore. Some view it as an act of charity (the way lawyers might take on pro bono cases), but the laws regarding insurance segregation have gotten stricter and the logistics of it have become so burdensome that many just view Medicare as too much of a liability. It's one of the reasons Medicare patients have such horrific wait times to see doctors, particularly specialists.
Hospitals take Medicare because many of them are legally required to. If they're part of larger hospital systems, they can also play interesting tricks to manage the respective patient populations without explicitly discriminating based on insurance provider, which has been another major force behind the massive consolidation of hospital systems that we've seen over the last decade.
The other major force, incidentally, is that many of them have been going bankrupt, and are being bought out either by other hospital groups or by insurance companies.
Well, independent private practices have been dying out for precisely this reason, and outside of Critical Access regions (which have a higher fee structure), many don't anymore. Some view it as an act of charity (the way lawyers might take on pro bono cases), but the laws regarding insurance segregation have gotten stricter and the logistics of it have become so burdensome that many just view Medicare as too much of a liability. It's one of the reasons Medicare patients have such horrific wait times to see doctors, particularly specialists.
Hospitals take Medicare because many of them are legally required to. If they're part of larger hospital systems, they can also play interesting tricks to manage the respective patient populations without explicitly discriminating based on insurance provider, which has been another major force behind the massive consolidation of hospital systems that we've seen over the last decade.
The other major force, incidentally, is that many of them have been going bankrupt, and are being bought out either by other hospital groups or by insurance companies.
yeah the doc-in-a-box practice is rapidly becoming a thing of the past. However the corporatization of medicine is not doing anyone any favors save for the administrators, and even then only the executives make out like bandits.
This is interesting -- suppose that the choke point of negotiation was handled by the government on behalf of citizens, but the administration of programs was privatized? That could be interesting.
Lord knows I've had about enough red tape for several lifetimes from NIH, NSF, and similar organs; Medicare as it now stands somehow manages to result in both medicine-at-a-loss and also fraud on a spectacular scale. I'm not a big fan of government but between consolidation and fragmentation, I don't think the current medical care solution is working, nor is it sustainable.
Lord knows I've had about enough red tape for several lifetimes from NIH, NSF, and similar organs; Medicare as it now stands somehow manages to result in both medicine-at-a-loss and also fraud on a spectacular scale. I'm not a big fan of government but between consolidation and fragmentation, I don't think the current medical care solution is working, nor is it sustainable.
[deleted]
Private insurance is a big once since the Dr bills $xx with the expectation that insurance will only agree to pay a % of that amount(but different amounts from different insurers and clients). In BC doctors know up front what they'll get back so they don't have to play pricing games.
> What are the factors in the American system that prevent reasonable pricing?
One major factor is the administrative cost for medical providers when dealing with insurance. That's why the cash price for medical services is often much cheaper
One major factor is the administrative cost for medical providers when dealing with insurance. That's why the cash price for medical services is often much cheaper
Take a close look at physician salaries in US vs. Canada.
If you're going to cut costs, you're going to have to convince physicians to take a pay cut.
If you're going to cut costs, you're going to have to convince physicians to take a pay cut.
I can't get over the cognitive dissonance of these two points:
> (2) Californians, as individuals, employers, and taxpayers have experienced a rise in the cost of health care and health care coverage in recent years
> (4) Individuals often find that they are deprived of affordable care and choice because of decisions by health benefit plans guided by the plan’s economic needs rather than consumers’ health care needs.
So (2) is saying health care costs are rising, which is bad. And (4) is saying insurance companies are making decisions based on price, which is also bad. You can't have it both ways. Either we should keep costs down, in which case some procedures will be denied as they are too expensive, or we pay for every procedure imaginable, causing prices to go up.
> (2) Californians, as individuals, employers, and taxpayers have experienced a rise in the cost of health care and health care coverage in recent years
> (4) Individuals often find that they are deprived of affordable care and choice because of decisions by health benefit plans guided by the plan’s economic needs rather than consumers’ health care needs.
So (2) is saying health care costs are rising, which is bad. And (4) is saying insurance companies are making decisions based on price, which is also bad. You can't have it both ways. Either we should keep costs down, in which case some procedures will be denied as they are too expensive, or we pay for every procedure imaginable, causing prices to go up.
Yes you can. As a 6th largest economy in the world [1] California can negotiate prices down by 50-60% to be comparable to Canada/UK. [2]
Besides, the existing state program (medi-cal) already covers over 1/3 of CA residents [3]. So it looks like if we lower the cost by 60% we can get pretty close to normal healthcare situation using the existing budget.
[1] https://en.wikipedia.org/wiki/Comparison_between_U.S._states...
[2] https://www.washingtonpost.com/news/wonk/wp/2013/03/26/21-gr...
[3] https://en.wikipedia.org/wiki/Medi-Cal
Besides, the existing state program (medi-cal) already covers over 1/3 of CA residents [3]. So it looks like if we lower the cost by 60% we can get pretty close to normal healthcare situation using the existing budget.
[1] https://en.wikipedia.org/wiki/Comparison_between_U.S._states...
[2] https://www.washingtonpost.com/news/wonk/wp/2013/03/26/21-gr...
[3] https://en.wikipedia.org/wiki/Medi-Cal
I don't think California will negotiate prices down by 50%, and I would bet on that (conditional on this bill passing). Anyone - old-gregg? - want to take that bet at even odds? I suggest using the total cost of one each from the list of medical services in old-gregg's second footnote - angiogram, office visit, angioplasty, etc. I'm also open to other terms.
(Studies show[0] that people answer politically-charged questions more accurately when paid for accuracy, so I think we'd have better debates if people bet on their predictions.)
[0] http://www.pewresearch.org/fact-tank/2013/06/17/political-vi...
(Studies show[0] that people answer politically-charged questions more accurately when paid for accuracy, so I think we'd have better debates if people bet on their predictions.)
[0] http://www.pewresearch.org/fact-tank/2013/06/17/political-vi...
It sounds fanciful to say that we'll just use our existing Medi-cal budget but now it will cover everyone.
If the government had so much bargaining power, then Medicare and Medi-cal would already have far smaller costs. We don't really see that.
Also, who exactly, would we be negotiating with? I don't know that you can squeeze the budgets of hospitals in California by 50% and have everything carry on like normal.
If the government had so much bargaining power, then Medicare and Medi-cal would already have far smaller costs. We don't really see that.
Also, who exactly, would we be negotiating with? I don't know that you can squeeze the budgets of hospitals in California by 50% and have everything carry on like normal.
Except that the lawmakers in Washington actually wrote the laws to forbid the government from negotiating for special rates for Medicare and Medicaid, unlike the UK or Canada. Which is why drugs there, for example, are so much cheaper than in the U.S.
Hmm, interesting. I know medicare reimbursement rates are still quite low compared to private insurance, so I wonder how that squares with a 'no negotiation' policy.
Edit: One study from Texas found that Medicare reimbursement rates were 70-80% below the private average. https://www.texmed.org/June16Journal/
Edit: One study from Texas found that Medicare reimbursement rates were 70-80% below the private average. https://www.texmed.org/June16Journal/
> can negotiate prices down by 50-60%
You can only do that by paying Doctors less.
Good luck with that. If you did it anyway, good luck finding enough Doctors.
When people think "negotiate prices" they usually think of drugs, but Doctors is the real problem.
Medi-Cal (and Medicaid in general for all states) only works because the regular rates subsidize the under-market charity rates. That only works up to a point, then it doesn't.
That BTW is why hospitals never publish rates - they need the higher rates to subsidize the charity rates.
Until you change that, you will never have single payer, it's impossible to do.
You can only do that by paying Doctors less.
Good luck with that. If you did it anyway, good luck finding enough Doctors.
When people think "negotiate prices" they usually think of drugs, but Doctors is the real problem.
Medi-Cal (and Medicaid in general for all states) only works because the regular rates subsidize the under-market charity rates. That only works up to a point, then it doesn't.
That BTW is why hospitals never publish rates - they need the higher rates to subsidize the charity rates.
Until you change that, you will never have single payer, it's impossible to do.
Physician pay (last I checked) only makes up about 20%, including the costs of them practicing. They see about half of it in the end. There is even more spent on administration, which makes up about 25% of spending. Compare that 25% to the 9% in Canada and it becomes pretty obvious where you can save money.
> Physician pay (last I checked) only makes up about 20%
Does that number include specialists? Nurses? Lab technicians?
If not, why are you excluding them?
You basically have 4 expenses: Durable Equipment, Medication, Salary, Facilities.
I suspect that Salary is the largest one, and the hardest to reduce.
Does that number include specialists? Nurses? Lab technicians?
If not, why are you excluding them?
You basically have 4 expenses: Durable Equipment, Medication, Salary, Facilities.
I suspect that Salary is the largest one, and the hardest to reduce.
Costs across the board are higher due to structural and incentive factors - more intervention, more fee for service, etc. also, specialists' income has risen ridiculously vs. GPs .
http://www.healthbeatblog.com/2008/01/health-care-s-1-2/
http://www.vox.com/a/health-prices#chart/11
http://www.healthbeatblog.com/2008/01/health-care-s-1-2/
http://www.vox.com/a/health-prices#chart/11
The pharma and medical instrument pricing racket is unbelievable. Took a look at the cost for our last delivery - of the $36k+ cost billed, facilities, equipment and medication were way over the billed rate of the doctors/nurses/anesthesiologists.
That number includes specialists and lab techs. It doesn't include hospital care (i.e. nurses).
You are just ignoring the profiteering done by the drug and insurance companies and the savings due to streamlining administration that a single payer system would bring.
You are just ignoring the profiteering done by the drug and insurance companies and the savings due to streamlining administration that a single payer system would bring.
The driver of the cost of insurance is the cost of care, and I haven't seen much, even in the form of rhetoric, paid this way.
So, can they really? Part of the reason places like Canada and the UK can do this is they can threaten to run around the industry when they try to fleece their citizens. Ultimately CA may be unable to do anything to combat the costs of medical care because the laws that give pharmacies and the AMA their monopoly in the field are enacted at the federal level.
So, can they really? Part of the reason places like Canada and the UK can do this is they can threaten to run around the industry when they try to fleece their citizens. Ultimately CA may be unable to do anything to combat the costs of medical care because the laws that give pharmacies and the AMA their monopoly in the field are enacted at the federal level.
Why can't California do the same and refuse to cover medications unless the sellers cooperate on price?
There is also no reason why you cant operate a single payer scheme AND a private insurance scheme in parallel, its just that EVERYBODY should contribute to the single payer scheme, whether they need it of not.
Some of the numbers for [2] confuse me. How can an office visit cost $30 in Canada? When I go in for an office visit, it typically takes about 30 minutes of staff time, around 15 minutes with a medical assistant and 15 minutes with a doctor. If that's $30, the implied wage is $60/hr for the medical staff, if you assume that all the money goes to staff. That just doesn't seem feasible.
Some of the other numbers seem more reasonable, though I should point out the charts are a bit misleading as they list the US 95th percentile in addition to the averages, which makes the difference appear larger than it really is.
Some of the other numbers seem more reasonable, though I should point out the charts are a bit misleading as they list the US 95th percentile in addition to the averages, which makes the difference appear larger than it really is.
A doctors visit isn't a good example. Folks don't go bankrupt from doctors visits. The important stuff is drugs and hospitals.
For example an asthmatic in any other country in the world pays ~$10 for a Ventolin inhaler (including tax and a % of profit), Americans pay $55-$65 and that price is increasing.
For example an asthmatic in any other country in the world pays ~$10 for a Ventolin inhaler (including tax and a % of profit), Americans pay $55-$65 and that price is increasing.
It's around $50 for 'off plan' visits (your not a canadian resident, or it's not covered by the healthcare plan).
The math should be $120/hr for the office. The assistant gets $20/hr and the doctor gets $100/hr. If you use the $50 rate, then it's $200/hr. If the doctors share an assistant, it becomes even more efficient. Because of the lower prices, there are less doctors, so they get higher utilization rates for the ones that are there.
The math should be $120/hr for the office. The assistant gets $20/hr and the doctor gets $100/hr. If you use the $50 rate, then it's $200/hr. If the doctors share an assistant, it becomes even more efficient. Because of the lower prices, there are less doctors, so they get higher utilization rates for the ones that are there.
Some office visits are shorter then others. (Although less scrupulous doctors in Canada aggressively optimize for faster visits - more money for them, worse outcomes for their patients.)
I heard this described as the "cost disease" issue (https://slatestarcodex.com/2017/02/09/considerations-on-cost...).
HN discussion: https://news.ycombinator.com/item?id=13613687
But also: https://hn.algolia.com/?query=cost%20disease
HN discussion: https://news.ycombinator.com/item?id=13613687
But also: https://hn.algolia.com/?query=cost%20disease
In a single payer system, there wouldn't be an insurance company sitting between a patient and the medical provider, extracting rent. The middleman and associated overhead would not exist (or be centralized), which could make the market more efficient.
OK, let's talk about overhead. Every doctor's office has one or two people per doctor who fight with insurance companies to see that the doctor gets paid. Every insurance company has people who fight with the doctors' people, trying to find ways to not pay them. Those people - on both sides - are a total waste to the business of actually delivering healthcare to people. Yes, we could cut a lot of overhead by getting rid of them.
That works... right up until the healthcare scheme is underfunded by the legislature, and then the single payer tries to find ways to reduce payments to the doctors, and then the overhead comes right back. So to reduce the overhead, the rules have to be really rules, not something the single payer tries to play with in order to control expenses.
Is that enough to get old-gregg's 50-60% reduction in expenses? I don't know. I'm a bit skeptical. It will get a large chunk of the way there, though.
That works... right up until the healthcare scheme is underfunded by the legislature, and then the single payer tries to find ways to reduce payments to the doctors, and then the overhead comes right back. So to reduce the overhead, the rules have to be really rules, not something the single payer tries to play with in order to control expenses.
Is that enough to get old-gregg's 50-60% reduction in expenses? I don't know. I'm a bit skeptical. It will get a large chunk of the way there, though.
I'm entirely in favor of a single payer system as it makes the most sense in my mind, but there is still a middleman.
Bureaucrats don't work for free.
Bureaucrats don't work for free.
A third alternative would be to increase efficiency so you can have the same level of care for less money.
Other countries spend far less on health care for similar quality, so it's possible.
Other countries spend far less on health care for similar quality, so it's possible.
No, there's another option: Health care company profits could go down. (But I suspect that people who want both (2) and (4) overestimate how far they can go before they reach zero, at which point we quit having health care companies, and then we have no health care coverage...)
Either way you're going to be reducing rent (ie, gaining market efficiency) until you're not doing that anymore. There are testable ways to evaluate the market's ability to handle cost reductions and operate effectively. Even better that California can rely on the US and Canadian market overall to compare itself.
Seems like an interesting idea. With California being the only state in the country doing this, I wonder what is there to stop people from other states using it. Someone from Washington or Texas driving up and getting a short term apartment/changing their ID just so they are covered for a really expensive surgery.
It seems like if they're the only state doing it, it'd be a target for the entire nation to go to when they really need care they cannot afford where they are currently.
It seems like if they're the only state doing it, it'd be a target for the entire nation to go to when they really need care they cannot afford where they are currently.
You could say the same thing for people qualifying for in-state tuition to University of California colleges (which is significantly cheaper than out-of-state tuition). Just moving to CA and making yourself a CA resident isn't enough, I think the rule there is you need have physically lived in a residence in CA for 1 year and intend to stay living in CA.
No reason why they couldn't make a similar restriction for health care.
No reason why they couldn't make a similar restriction for health care.
[deleted]
Same way as it's solved in Canada - each province manages it's own healthcare system and provides health insurance cards to its residents. You get health insurance IFF you're resident, and you're resident IFF you pay taxes in that province. So that lines up
If this would replace my private health insurance premiums with State taxes, I'd have about $21,600 to contribute for a family of 4, generally healthy humans.
- Does it mean no such thing as 'in or out of network'? That alone cost me $10,000 in 2015, over an above the $21,600 premiums.
- Will it be PPO or HMO-style? Some of us like Kaiser, some don't.
- Will I be forced to change providers? A real sore spot from the ACA for me.
I guess I'm saying, do it, but for God's sake, get it right the first time.
- Does it mean no such thing as 'in or out of network'? That alone cost me $10,000 in 2015, over an above the $21,600 premiums.
- Will it be PPO or HMO-style? Some of us like Kaiser, some don't.
- Will I be forced to change providers? A real sore spot from the ACA for me.
I guess I'm saying, do it, but for God's sake, get it right the first time.
As a CA small business owner, I'd be much happier to just pay a simple payroll tax per employee than have this multi-step octopus process around open enrollment periods, health insurance brokers, differing city regulations (like SF), multiple vendors, audits, etc.
Single payer would also make hiring and HR a lot simpler.
Single payer would also make hiring and HR a lot simpler.
In Canada it's like one very large HMO that covers the country or province.
Part of single payer is not being able to avoid participation. I don't know if your provider will be able to avoid participating unless they move out of CA.
Part of single payer is not being able to avoid participation. I don't know if your provider will be able to avoid participating unless they move out of CA.
Anything that moves us beyond the gross waste and incompetence of insurance and medical billing is a good thing.
My wife and I had a few recent medical issues crop up and, despite having decent coverage, have had to deal with chasing down providers and third parties who consistently fail to bill even the most basic procedures properly.
I'd much rather pay more in taxes to have the knowledge we'd be safely covered without dealing with the headache of endless middlemen who add no value to the system.
My wife and I had a few recent medical issues crop up and, despite having decent coverage, have had to deal with chasing down providers and third parties who consistently fail to bill even the most basic procedures properly.
I'd much rather pay more in taxes to have the knowledge we'd be safely covered without dealing with the headache of endless middlemen who add no value to the system.
I think this is great. California gets to experiment with a single payer system and I, as a Utahan, get to watch and see whether it works or not. Unless it completely fails, then we'll all need to bail Cali out. Can we try this in North Dakota first? ;)
Why would you as a Utahn need to bail out California? You know that CA ran deficits for years?
Be happy - just like MJ legalization, this is true federalism at work - states rights and all.
Of course, as a CA resident, I'd be happy that people here have an option aside from the horrible individual insurance market (which, despite Obamacare, is still very expensive).
Be happy - just like MJ legalization, this is true federalism at work - states rights and all.
Of course, as a CA resident, I'd be happy that people here have an option aside from the horrible individual insurance market (which, despite Obamacare, is still very expensive).
Worked for many other countries. Seems to be quite a bit cheaper for individuals and nations as well. Not sure if it will work on a state level though.
Only if CA can negotiate lower costs, especially pharmaceuticals.
and establish uniform pricing for services across the board
Not sure if that's totally fair, Califoria is very diverse. Rates that work in SF might not work in rural CA.
It's reasonably easy to establish pricing differences relative to land value costs to account for increased rent in the area. It's almost the same way the GSA determines Per Diem rates. https://www.gsa.gov/portal/category/100120
I will 100% be moving to Cali if this passes. I won't mind paying higher taxes for this as well. Right now my shit health care plan costs me $260/month in MI. If the taxes increase by 300-400/month I'm all for it and will gladly pay it.
California is roughly the size of Italy, its economy slightly larger but essentially comparable. Italy has single payer and one of the best healthcare outcomes in the world with one of the lowest expenditure per patient in developed countries. Quality of service is uneven geographically (but it's no different anywhere else) and in generally getting care in Italy is a no hassle experience.
California, learn from Italy.
California, learn from Italy.
I congratulate the senators on proposing universal health-care in a way that in federally Constitutional: that is, through the states!
Though I'm usually skeptical of government overreach and innefficiency, I do believe a minimum of preventative care would save people and the system a lot in terms of money, time, and life. So go for it, and let the rest of the country see how it goes.
Though I'm usually skeptical of government overreach and innefficiency, I do believe a minimum of preventative care would save people and the system a lot in terms of money, time, and life. So go for it, and let the rest of the country see how it goes.
Coming from a country with single-payer healthcare:
If you have have 5 beds, and 10 people that need to use a bed every day, there is no pure finance management solution to solve it.
If you have insurance-based system like in US, only people who can afford insurance will be able to use the beds. Rest will be priced-out.
If you have single-payer system like in my country of origin (and what a lot of people in America would want), people will be queued and/or to some extent squeezed to fit on what's available. It often leads to corruption, when people pay extra to cut the line. Or there are some officially approved way to pay your way to get your bed fast and without overcrowding.
The reality is of course a bit more complicated, but the point is: the real solution is to either have more beds, or to have less people who need to use them. Why can't more beds be built and operated cheaply? Why there is so many people needing them?
If you have have 5 beds, and 10 people that need to use a bed every day, there is no pure finance management solution to solve it.
If you have insurance-based system like in US, only people who can afford insurance will be able to use the beds. Rest will be priced-out.
If you have single-payer system like in my country of origin (and what a lot of people in America would want), people will be queued and/or to some extent squeezed to fit on what's available. It often leads to corruption, when people pay extra to cut the line. Or there are some officially approved way to pay your way to get your bed fast and without overcrowding.
The reality is of course a bit more complicated, but the point is: the real solution is to either have more beds, or to have less people who need to use them. Why can't more beds be built and operated cheaply? Why there is so many people needing them?
> The real solution is to either have more beds, or to have less people who need to use them.
This is exactly the incentives we've wanted all along. Is healthcare too expensive to cover everyone's current level of need? Now it finally makes sense for government to get serious about investing in prevention.
Our current incentives of "the more sick-care you provide, the more you get paid" has exactly the opposite incentive. No solution is perfect, but this feels like a significant step in the right direction.
This is exactly the incentives we've wanted all along. Is healthcare too expensive to cover everyone's current level of need? Now it finally makes sense for government to get serious about investing in prevention.
Our current incentives of "the more sick-care you provide, the more you get paid" has exactly the opposite incentive. No solution is perfect, but this feels like a significant step in the right direction.
If you have have 5 beds, and 10 people that need to use it every day, there is no financial solution to solve it.
One financial solution would be to fund construction of the infrastructure to house the beds and fund the operational expenditure to run them.
I would guess the reasons this doesn't happen are primarily political.
One financial solution would be to fund construction of the infrastructure to house the beds and fund the operational expenditure to run them.
I would guess the reasons this doesn't happen are primarily political.
Here is the problem. How do you deal with illegal immigrants? At least in the current system there are ways for them to get treated, but in a single payer system?
Single-payer works great in countries were everyone have a ssn. Not sure its feasible in the US as much as i think it would be great.
Single-payer works great in countries were everyone have a ssn. Not sure its feasible in the US as much as i think it would be great.
By giving them healthcare? There aren't actually a large number of illegal immigrants sitting around contributing nothing to the CA economy.
I did a quick search and an estimated 11 million illegal immigrants pay an estimated $11.6 billion in taxes, so $1,000 per person.
It's a huge net loss. Not to mention the fallout from stolen SSNs and creating demand for stolen SSNs
It's a huge net loss. Not to mention the fallout from stolen SSNs and creating demand for stolen SSNs
You're making an incorrect assumption that taxes paid are proportional to GDP contribution. Do you really think that, for example, low-paid migrant farm workers contribute correspondingly little to economic output? They contribute hugely to farm output!
As an extreme example, unpaid workes (slaves in places and times with slavery, interns, etc) still contribute to their employers' output. The right thing to do isn't to reduce their rights and benefits to be commensurate with their nonexistent salaries; instead, their rights and benefits (and hence taxes) should be increased to be (at least) commensurate with their value to the economy.
The stolen SSN issue is a bizarre strawman. There's a trivial solution: give them real SSNs.
As an extreme example, unpaid workes (slaves in places and times with slavery, interns, etc) still contribute to their employers' output. The right thing to do isn't to reduce their rights and benefits to be commensurate with their nonexistent salaries; instead, their rights and benefits (and hence taxes) should be increased to be (at least) commensurate with their value to the economy.
The stolen SSN issue is a bizarre strawman. There's a trivial solution: give them real SSNs.
its not that easy. Once you have a single payer system suddenly you need to follow a budget. You now have to put limits on how many can be treated, for what, what kind of treatments and machines you have budgets for. Thats the thing with healtcare you can never spent enough on it and that alone will affect the willingness to pay for others.
A lot of them even pay taxes with stolen SSNs!
You just treat them like anyone else and the cost gets rolled into the cost of coverage for everyone. Hospitals and ERs are already required to treat people who come in regardless of whether they are legal/illegal or have/don't have insurance. So... we pay for their (and citizens who can't afford their coverage) care anyways. With single payer that cost would just be spread across everyone in the state rather than spread across only people with insurance.
In a single payer system thats not going to work. Keep in mind that you don't make money anymore you have a taxpayer paid budget. Thats not going to leave room for that.
That they are required to treat is even worse for a budget it wouldnt hold long.
That they are required to treat is even worse for a budget it wouldnt hold long.
I do not understand your argument. You just price a new tax high enough such that the system is paid for, no? I think everyone agrees that you need a new tax to pay for the system, and you are not going to take the current tax revenue and pay for single payer plus everything else the government pays for. Instead of paying for insurance premiums or getting a lower salary because health insurance is part of your compensation, you would just pay a new tax. As a result your life would be simplified since you no longer would need to worry about insurance networks, levels of coverage, out-of-network doctors in in-network-hospitals, etc.
in the real world you dont just do that. The problem is that you can never pay too much for healthcare so how much tax you are going to pay is important.
The US is a big and complex country, its not like other countries and so you run the risk of having to tax so high to make it sustainable that its dead on arival.
The US is a big and complex country, its not like other countries and so you run the risk of having to tax so high to make it sustainable that its dead on arival.
>How do you deal with illegal immigrants?
You deport them? Doesn't seem like a big problem.
You deport them? Doesn't seem like a big problem.
Deport them or not, but after treating them, because healthcare is a basic human right. Definitely a non-problem compared to a healthcare system that is incenticized to profit from the sick rather than prevent long-term health issues and keep the population healthy as a whole.
How does this stop illegal immigrants getting treated the same way they do now?
You can pay out of pocket. The second you get into free healtcare you need to suddenly track things on federal and state level to make sure budgets are kept. I am a fan of single payer but its a very different beast and i am not sure its possible in a US context.
So, right now, they have to pay out of pocket. With a public system, they can also pay out of pocket. So no difference.
I don't know why Americans pretend that a public heathcare system necessarily means the sudden end to all private services overnight. Here in Australia you're more than welcome to have your own private insurance or pay out of pocket for treatment.
I don't know why Americans pretend that a public heathcare system necessarily means the sudden end to all private services overnight. Here in Australia you're more than welcome to have your own private insurance or pay out of pocket for treatment.
The number of illegal immigrants in the US is around 11 million.
Healthcare is one of the most expensive posts in any society. The US system is not built for single payer model which means many other areas will have to change too.
What normally happens when you make a public healthcare system and allow for private enterprise (which I am a fan of having) is that the primary burden (cancer, long term illness, major surgeries) are put in the hands of the public hospitals while the private ones deal more with things like cosmetic plastic surgery and other treatments which are lucrative.
Most public healthcare systems with a single payer model have to heavily prioritize how man can get treatment, for what, with what kind of technology etc.
It's not just a matter of switching from one kind of insurance model to another it's about turning hospitals into places who can't make money but have to adhere to a budget. It's a very very different kind of system that comes out of that and in a country like the US with that many illegal immigrant I am not sure it can work financially.
Healthcare is one of the most expensive posts in any society. The US system is not built for single payer model which means many other areas will have to change too.
What normally happens when you make a public healthcare system and allow for private enterprise (which I am a fan of having) is that the primary burden (cancer, long term illness, major surgeries) are put in the hands of the public hospitals while the private ones deal more with things like cosmetic plastic surgery and other treatments which are lucrative.
Most public healthcare systems with a single payer model have to heavily prioritize how man can get treatment, for what, with what kind of technology etc.
It's not just a matter of switching from one kind of insurance model to another it's about turning hospitals into places who can't make money but have to adhere to a budget. It's a very very different kind of system that comes out of that and in a country like the US with that many illegal immigrant I am not sure it can work financially.
Oh ya, Illegal immigrants totally pay their medicals bills after going to the emergency room.
Most countries just deny them public healthcare in the first place. You know, like happens already in the US right now.
The US system is more complex than that. There are plenty of illegal immigrants who get treated in the healthcare system today. As long as you have money you can get treated. In a public healthcare system you have to be identified as legal citizen in order to get access to the system. The system are going to have quotas of how many people are allowed to get treated with what etc. How do you think the general taxpayer is going to react to that?
It's as simple as you try to make it sound like.
It's as simple as you try to make it sound like.
I don't think single payer is viable in the US, yet I am happy that it is being attempted here. America was originally designed to be a marketplace of ideas. With a limited federal government each state can enact laws that it sees fit. If the law works well, more states will adopt it.
This is a perfect example of "states rights" at work. I hope it gets implemented (if the people of California wish it so) and that comprehensive data is provided so I and others can make a truly informed decision on the matter.
This is a perfect example of "states rights" at work. I hope it gets implemented (if the people of California wish it so) and that comprehensive data is provided so I and others can make a truly informed decision on the matter.
I don't understand this. Maybe I'm uneducated on "acts"?
> It is the intent of the Legislature to enact legislation that would establish a comprehensive universal single-payer health care coverage program and a health care cost control system for the benefit of all residents of the state.
This is literally the meat of the bill. The actual changes would still have to be voted on in separate bills, right? What is the point of this?
> It is the intent of the Legislature to enact legislation that would establish a comprehensive universal single-payer health care coverage program and a health care cost control system for the benefit of all residents of the state.
This is literally the meat of the bill. The actual changes would still have to be voted on in separate bills, right? What is the point of this?
The CA legislature uses a good deal of intent legislation. I assume the purpose is to formally announce the beginning of legislative development process, allowing stakeholders to become involved.
> Maybe I'm uneducated on "acts"?
"acts" are how smarter Californians let the lesser Californians what to do.
> What is the point of this?
To make people feel good about themselves.
"acts" are how smarter Californians let the lesser Californians what to do.
> What is the point of this?
To make people feel good about themselves.
Welcome to the rest of the civilised world.
if health care prices were mandated to be public (like calorie counts on food) then we would all be better off
Knowing health care prices doesn't help much, though. If you break your leg, you aren't going to go to a bunch of different hospitals, compare prices, and choose the best value option. If you are in a car accident and unconscious, the paramedic isn't going to figure out where you can get the best deal.
Medical decisions are a TERRIBLE candidate for a free market. You are never in a position to be a rational actor in them.
Medical decisions are a TERRIBLE candidate for a free market. You are never in a position to be a rational actor in them.
Healthcare is such a massive hurdle to entrepreneurship, this would be huge!
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It has very little effect if any. denmark have a true single payer system and social wellfare program you can only dream of in the us. Yet the number of startups created are declining just like ine the us. It creates a very different mindset.
We don't know what the effect would be since we've never had a single payer system. In addition, Europe has a number of other labor laws that do not exist in the U.S. as well as other corporate regulations so there is no apples-to-apples comparison.
So I agree that adding single payer or changing the healthcare system to have more government involvement probably won't have much effect, but I don't agree that the single-payer + welfare system is the reason why they have different levels of startups in Denmark.
So I agree that adding single payer or changing the healthcare system to have more government involvement probably won't have much effect, but I don't agree that the single-payer + welfare system is the reason why they have different levels of startups in Denmark.
Not what i said. Look at parent to what i am answering. Current system was positioned as a burden for startups, my point is simply that healthcare is a burden no matter whst and that changing the system wont make it less a burden, it will just have consequences other places.
Do Danes not create "startups" or not create "small businesses"? I keep on referring to Japan, but there's a deserved reputation of it being impossible to create a tech startup there.
But that doesn't mean there's no entrepreneurs, they're just called small businesses and are running grocery stores, graphic design agencies, anime studios, etc.
What lets you create a "startup" is VC and banks with huge appetites for risk and allowing your business to fail.
But that doesn't mean there's no entrepreneurs, they're just called small businesses and are running grocery stores, graphic design agencies, anime studios, etc.
What lets you create a "startup" is VC and banks with huge appetites for risk and allowing your business to fail.
It creates a very different mindset.
Danes aside, are you saying that single payer healthcare would convince Californians to be more conservative towards entrepreneurship?
Danes aside, are you saying that single payer healthcare would convince Californians to be more conservative towards entrepreneurship?
No i am saying that its not going to change anything and that longer term it changes how people think of risk.
I find that a bold assertion.
Yeah well i have tried both.
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Given how much this country honours its armed forces, I guess we can reasonably expect the standard of care and efficiency to be, at most, equal to that of the Veterans Administration (VA)
Will there be a private insurance alternative? Many of my parents' Canadian friends visit the US for complex procedures and surgeries (because of both quality and wait times).
Assuming this is implemented, how does it work in case of Californians traveling in other states/countries? Will it work like the current out-of-network case, that the government reimburse you some percentage, with some restrictions (ER only, for example)? Or will the Californians need to buy a separated insurance before they travel?
How does this work for single-payer countries, like Canada?
How does this work for single-payer countries, like Canada?
Who will pay for it?
California tax payers, obviously.
Perhaps the bulk of it will come from folks (and companies?) who have driven real estate prices up to the point no working class person can afford to buy a home in any major city in California.
There may be some negative consequences to that, as well, in the form of some companies or people moving out of California. But, hey, maybe that'd help solve the housing crisis. And, it's also a competitive advantage on some vectors, so maybe it would have a net positive impact on economic growth in the state.
I, honestly, have no idea how it'd work, especially for a state that has managed to have a budget crisis seemingly every year for decades (but, maybe this is just me having a selective memory). But, the CA economy is very, very, big (the biggest, and bigger than many other states combined). If any state could do it, it would be CA.
It'd be interesting, anyway. Somebody has to go first.
Perhaps the bulk of it will come from folks (and companies?) who have driven real estate prices up to the point no working class person can afford to buy a home in any major city in California.
There may be some negative consequences to that, as well, in the form of some companies or people moving out of California. But, hey, maybe that'd help solve the housing crisis. And, it's also a competitive advantage on some vectors, so maybe it would have a net positive impact on economic growth in the state.
I, honestly, have no idea how it'd work, especially for a state that has managed to have a budget crisis seemingly every year for decades (but, maybe this is just me having a selective memory). But, the CA economy is very, very, big (the biggest, and bigger than many other states combined). If any state could do it, it would be CA.
It'd be interesting, anyway. Somebody has to go first.
> I, honestly, have no idea how it'd work, especially for a state that has managed to have a budget crisis seemingly every year for decades
Those crises were artifacts of requiring a supermajority for passing a budget, which meant as long as parties voted as blocks, the minority party could prevent the majority party from passing any budget; crises were, then, deliberately engineered to extract concessions. Since going to a majority-rule for passing budgets (retaining the supermajority requirement for tax increases), the annual budget crises have disappeared.
Those crises were artifacts of requiring a supermajority for passing a budget, which meant as long as parties voted as blocks, the minority party could prevent the majority party from passing any budget; crises were, then, deliberately engineered to extract concessions. Since going to a majority-rule for passing budgets (retaining the supermajority requirement for tax increases), the annual budget crises have disappeared.
All of its residents.
In theory they could have a problem with really sick people moving to California for the healthcare, raising their costs. But that takes time, so maybe before it becomes a big problem, other states will do similar things.
This isn't really an "in theory." Welfare states are fundamentally incompatible with open borders until we live in a world where equivalent levels of welfare are available everywhere. The incentives just don't add up.
On the other hand it could still work if the benefit is only available to Californians who have lived there for X years. Not sure about the legality of this though -- states can discriminate this way for in-state University tuition, but in Zobel v. Williams the Supreme Court ruled that Alaska couldn't pay out Permanent Fund dividends based on how long you had lived in Alaska (https://en.wikipedia.org/wiki/Alaska_Permanent_Fund).
On the other hand it could still work if the benefit is only available to Californians who have lived there for X years. Not sure about the legality of this though -- states can discriminate this way for in-state University tuition, but in Zobel v. Williams the Supreme Court ruled that Alaska couldn't pay out Permanent Fund dividends based on how long you had lived in Alaska (https://en.wikipedia.org/wiki/Alaska_Permanent_Fund).
Interesting idea.
In practice, I wonder if there'd be a grace period, e.g. your insurance doesn't kick in until you've lived in California a year. However, since so many jobs start your insurance benefits on day 1, I'd expect this would have to as well.
In practice, I wonder if there'd be a grace period, e.g. your insurance doesn't kick in until you've lived in California a year. However, since so many jobs start your insurance benefits on day 1, I'd expect this would have to as well.
Sans illegal aliens.
Of course, they also pay lots of taxes too, including sales tax, and presumably some of that, directly or indirectly, would offset the costs of this kind of program.
Well, even illegal immigrants pay taxes one way or another if they have a job or buy anything.
If that were true there would be no need for taxes. But in reality poor people will steal from non-poor people. That's what taxes are. "everybody pays" is a worthless statement if you don't include amounts.
A valid concern considering the state is projected to be running on a deficit before long [1]
[1] http://www.latimes.com/politics/la-pol-sac-jerry-brown-budge...
[1] http://www.latimes.com/politics/la-pol-sac-jerry-brown-budge...
Who pays for healthcare now? Why would it be harder to support in a cheaper system like single payer?
The taxpayers of the state would be the (trivial) cost this bill would incur (basically, the cost of printing it: it's a statement of intent and nothing more) out of existing taxes.
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I feel like you know the answer.
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This is gonna be great for a startup in California!
Seems like a bit of a work in progress...?
I wonder what the impact would be on the US insurance market if the state with the largest GDP dropped out?
What effects would this have on the currently generous insurance plans of $huge_tech_company_based_in_CA?
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I simultaneously believe in universal coverage as a moral imperative, but also the efficiency of markets over government AND basic income as a necessity as automation displaces millions of workers.
So, why not combine concepts - start off with basic income that has to be spent on health care insurance. Start with enough for coverage against major issues, but people can spend more for more coverage.
Universal coverage is attained immediately without any individual mandates. Giant, wasteful bureaucracies go away. Prices are controlled via market forces.
And it paves the way for a system of basic income...
So, why not combine concepts - start off with basic income that has to be spent on health care insurance. Start with enough for coverage against major issues, but people can spend more for more coverage.
Universal coverage is attained immediately without any individual mandates. Giant, wasteful bureaucracies go away. Prices are controlled via market forces.
And it paves the way for a system of basic income...
I'm pretty confident that if you get rid of individual mandates while not disqualifying sick people or enforcing benefit caps, premiums will skyrocket. I'm not sure there's really a middle ground here, it's just unavoidable actuary math.
So if it is, as you say, a moral imperative, what are your choices?
Maybe the EBI will need to be ridiculously high to actually provide the coverage you agree is a moral imperative to provide. But that doesn't really solve the problem, it just ends up meaning that sick people don't have that EBI to cover stuff everyone else can pay for with it. Like food and housing.
I'm open to hearing other ideas on how to do it, but I think that you'd have to vary the EBI based on how expensive health care is for the individual getting it, if your goal is to meet the universal coverage moral imperative. And that's very different from what EBI is supposed to be. I don't think it will solve the problem that you're describing.
So if it is, as you say, a moral imperative, what are your choices?
Maybe the EBI will need to be ridiculously high to actually provide the coverage you agree is a moral imperative to provide. But that doesn't really solve the problem, it just ends up meaning that sick people don't have that EBI to cover stuff everyone else can pay for with it. Like food and housing.
I'm open to hearing other ideas on how to do it, but I think that you'd have to vary the EBI based on how expensive health care is for the individual getting it, if your goal is to meet the universal coverage moral imperative. And that's very different from what EBI is supposed to be. I don't think it will solve the problem that you're describing.
The individual mandate is moot in this system, as everyone will have money they can only spend on insurance.
Benefit caps are a really tricky issue. As a society, are we willing to spend a million dollars to extend life for a week? Probably not. On the other hand, do you cut off a cancer patient after a million? Probably not. But there has to be a rational way to balance this without people freaking out over 'death-panels'.
I agree, universal coverage means vastly more money spent. Therefore, coverage for major issues is the baseline amount, not the Obamacare standards where people generally have way more insurance than they would choose.
The closest proposal I've seen is tax credits for this.
Benefit caps are a really tricky issue. As a society, are we willing to spend a million dollars to extend life for a week? Probably not. On the other hand, do you cut off a cancer patient after a million? Probably not. But there has to be a rational way to balance this without people freaking out over 'death-panels'.
I agree, universal coverage means vastly more money spent. Therefore, coverage for major issues is the baseline amount, not the Obamacare standards where people generally have way more insurance than they would choose.
The closest proposal I've seen is tax credits for this.
If they can only spend the EBI on insurance, it's a fixed health care subsidy or tax credit depending on how you frame it. I may simply be confused though, because every example I know of for EBI means "unrestricted base income".
Can we just call it something other than EBI if you're talking about restricting how it is spent?
In any event, if I understand you, it's a fixed amount per person.
That doesn't seem like it does much to address the moral imperative of guaranteeing affordable health care if sick people are on much more expensive health care plans or if the available affordable plans don't cover what they need. So you'd have to offer varying amounts depending on need, in order to meet that moral imperative.
And once you're talking about varying the amount, it is not very close to what I think you're describing.
Is there some way to reconcile these ideas and constraints that I'm missing? Because I suspect Congress would love to hear it...
Can we just call it something other than EBI if you're talking about restricting how it is spent?
In any event, if I understand you, it's a fixed amount per person.
That doesn't seem like it does much to address the moral imperative of guaranteeing affordable health care if sick people are on much more expensive health care plans or if the available affordable plans don't cover what they need. So you'd have to offer varying amounts depending on need, in order to meet that moral imperative.
And once you're talking about varying the amount, it is not very close to what I think you're describing.
Is there some way to reconcile these ideas and constraints that I'm missing? Because I suspect Congress would love to hear it...
And course no one should be disqualified. I don't think premiums would skyrocket, because as a major break with Obamacare, this is only enough for basic insurance.
Frankly, that's all we could possibly afford as a country. And maybe not even that.
The Obamacare concept of the young subsidizing the old via the individual mandate actually works in this scenario, because the young will all have insurance.
Frankly, that's all we could possibly afford as a country. And maybe not even that.
The Obamacare concept of the young subsidizing the old via the individual mandate actually works in this scenario, because the young will all have insurance.
The problems with your last argument are that almost nobody is actually a utilitarian, and utilitarianism is wrong.[1][2][3]
edit: full disclosure; I am an ethical intuitionist.[4]
[1] http://degreesofclarity.com/writing/utilitarianism/
[2] https://en.wikipedia.org/wiki/Trolley_problem
[3] https://en.wikipedia.org/wiki/Utilitarianism#Criticisms
[4] https://en.wikipedia.org/wiki/Ethical_intuitionism
edit: full disclosure; I am an ethical intuitionist.[4]
[1] http://degreesofclarity.com/writing/utilitarianism/
[2] https://en.wikipedia.org/wiki/Trolley_problem
[3] https://en.wikipedia.org/wiki/Utilitarianism#Criticisms
[4] https://en.wikipedia.org/wiki/Ethical_intuitionism
We detached this subthread from https://news.ycombinator.com/item?id=13825745 and marked it off-topic.
The Trolley problem isn't really an example of utilitarianism being wrong. Quite the opposite, I use that example to convince people of how awesome Utilitarianism is, not as a contradiction.
What, would you chose to kill 5 people, instead of one?
What, would you chose to kill 5 people, instead of one?
I gave that as an example of a controversial subject; many people prefer to let things be rather than interfere and kill one or more people. The organ donor example is much tougher.
There is no one moral philosophy that adequately covers every situation. If there was we'd just use that and not have all of these other options. They are tools to consider (and sometimes reject) just like other parts of philosophy.
What Utilitarianism is good for is making policy decisions that are not directly related to human rights, and therefore may not have a clear cut answer in other philosophies. [edit clarity]
What Utilitarianism is good for is making policy decisions that are not directly related to human rights, and therefore may not have a clear cut answer in other philosophies. [edit clarity]
But it sounds good to sell it to the "fiscal conservatives". I am not a utilitarian, but nobody likes to be hectored into doing things -- and it's easy for an argument from, e.g., personal morality to sound that way.
Have you ever convinced someone of something by using a utilitarian argument? I haven't.
I have become completely convinced that either nobody is a utilitarian (i.e. 'utilitarians' just frame their preferences as the utility-maximizing solution), or that there is no consistent way to evaluate utility.
I have become completely convinced that either nobody is a utilitarian (i.e. 'utilitarians' just frame their preferences as the utility-maximizing solution), or that there is no consistent way to evaluate utility.
so should the government force those people to spend their earned income on healthcare for others?
Absolutely not. Pretty much any question that starts with "should the government force ..." can be answered "no". You earned your income, it's yours and it should be up to you how to spend it.
Using force / aggression (aka the government forcing you to do something) is a violation of your most fundamental rights, and strips you of your agency and dignity as a human being. And while the end may sound noble ("everybody should have free health care") the truth is that nobody is in a better position to determine how your income should be spent than you, and nobody other than you has any standing to decide what kind of charity (if any) you should engage in.
Rather than stealing from Bobby to pay for Suzy's health-care, it would be better to enact policies that A. reduce the cost of health-care, and B. encourage general economic welfare, job creation, etc., such that both Bobby and Suzy can pay for their own health-care from the get-go.
Absolutely not. Pretty much any question that starts with "should the government force ..." can be answered "no". You earned your income, it's yours and it should be up to you how to spend it.
Using force / aggression (aka the government forcing you to do something) is a violation of your most fundamental rights, and strips you of your agency and dignity as a human being. And while the end may sound noble ("everybody should have free health care") the truth is that nobody is in a better position to determine how your income should be spent than you, and nobody other than you has any standing to decide what kind of charity (if any) you should engage in.
Rather than stealing from Bobby to pay for Suzy's health-care, it would be better to enact policies that A. reduce the cost of health-care, and B. encourage general economic welfare, job creation, etc., such that both Bobby and Suzy can pay for their own health-care from the get-go.
We detached this subthread from https://news.ycombinator.com/item?id=13825673 and marked it off-topic.
> the truth is that nobody is in a better position to determine how your income should be spent than you
This may be unpopular to say, but this is pretty demonstrably false.
Perhaps you've not heard of the free rider problem?
https://en.wikipedia.org/wiki/Free_rider_problem
This may be unpopular to say, but this is pretty demonstrably false.
Perhaps you've not heard of the free rider problem?
https://en.wikipedia.org/wiki/Free_rider_problem
> Using force / aggression (aka the government forcing you to do something) is a violation of your most fundamental rights, and strips you of your agency and dignity as a human being.
This is completely wrong. You have no rights except those guaranteed you by your fellows in a collective agreement. 'Rights' are exactly those things that the collective threatens us against violating in others.
Consider: if it's up to me to violently defend my 'rights' individually, then I am free to decide literally anything is my right. But the things your neighbors will fight others for on your behalf, these are your rights.
> the truth is that nobody is in a better position to determine how your income should be spent than you
Also plain wrong. How much of your income would you have chosen to spend on network protocol research in the late 1970s? Or on growing mold in dishes in 1910? We are much better at these decisions collectively.
This is completely wrong. You have no rights except those guaranteed you by your fellows in a collective agreement. 'Rights' are exactly those things that the collective threatens us against violating in others.
Consider: if it's up to me to violently defend my 'rights' individually, then I am free to decide literally anything is my right. But the things your neighbors will fight others for on your behalf, these are your rights.
> the truth is that nobody is in a better position to determine how your income should be spent than you
Also plain wrong. How much of your income would you have chosen to spend on network protocol research in the late 1970s? Or on growing mold in dishes in 1910? We are much better at these decisions collectively.
I just remembered that the mold was an accident. The bacteria were being grown in dishes. Science accuracy.
I understand that's the conservative/libertarian position - however the government forces you to pay taxes to support infrastructure and other things. Are you against that as well?
I understand that's the conservative/libertarian position
FWIW, conflating conservatism and libertarianism is a mistake. There's some incidental overlap, just like there is between libertarianism and liberalism, but that's pretty much the extent of it.
Are you against that as well?
Yes, of course. Basically, if the word "force" is involved, it's wrong. Come up with a way to collectively fund infrastructure that's voluntary and I'm all for it. But if your idea needs force / violence to be executed, then, well, maybe it isn't such a good idea after all.
FWIW, conflating conservatism and libertarianism is a mistake. There's some incidental overlap, just like there is between libertarianism and liberalism, but that's pretty much the extent of it.
Are you against that as well?
Yes, of course. Basically, if the word "force" is involved, it's wrong. Come up with a way to collectively fund infrastructure that's voluntary and I'm all for it. But if your idea needs force / violence to be executed, then, well, maybe it isn't such a good idea after all.
Right now, I can't think of a good way to have everyone voluntarily fund infrastructure. No nation-state has ever functioned without the threat of state-imposed force. It's not a pleasant reality, but nobody really knows how to do better at the moment. The only known alternative is scaling back civilization to pre-city-state conditions. But perhaps you have some suggestions on how to actually do this.
Regardless, this idea you have - that governmental "force", or any kind of institutional force that suppresses your individual will, is some kind of ultimate evil - seems very misguided. The laws of biology and physics will override your will and force you to degenerate and die. Micro-organisms will force you to cough up blood and die. Wild animals will force you to give up your flesh and die. Collective human institutions are the only things that have successfully imbued individual humans with an order of magnitude more power and more rights than our primitive ancestral conditions would allow. Many of these human institutions are also abusive, however there doesn't seem to be an alternative to forming collective human institutions that require forced large-scale group efforts if we want to actually not die of malaria all the time.
Regardless, this idea you have - that governmental "force", or any kind of institutional force that suppresses your individual will, is some kind of ultimate evil - seems very misguided. The laws of biology and physics will override your will and force you to degenerate and die. Micro-organisms will force you to cough up blood and die. Wild animals will force you to give up your flesh and die. Collective human institutions are the only things that have successfully imbued individual humans with an order of magnitude more power and more rights than our primitive ancestral conditions would allow. Many of these human institutions are also abusive, however there doesn't seem to be an alternative to forming collective human institutions that require forced large-scale group efforts if we want to actually not die of malaria all the time.
Some people will never have the means to pay for their own health care. Some jobs that have social value do not pay enough money to care for people. In your worldview, those people don't deserve to have health.
I'll stick with civilized societies thankyouverymuch.
I'll stick with civilized societies thankyouverymuch.
In your worldview, those people don't deserve to have health.
No, that is not my worldview, not in the slightest.
No, that is not my worldview, not in the slightest.
Unless you can provide health care for those who are able to in a way that doesn't end up in coercing someone to give their share of resources towards that, then whatever you think may happen, will end up in some people not having access to care.
Government is "forcing" very few people. Most people participate in society voluntarily.
For example, government doesn't force me to obey the law; I do it voluntarily. They don't force me to pay my bills, not shoot my neighbor, and pay my taxes. I do all that voluntarily.
EDIT: I don't follow Hacker News' rules and norms because I'm afraid of being banned, but because I respect the other people here, respect that there need to be rules, and respect our hosts' authority and need to make them. It's something (almost) all learn as children; it's healthy social interaction.
Most people are responsible members of their communities. The concept of force applies only to a very few.
For example, government doesn't force me to obey the law; I do it voluntarily. They don't force me to pay my bills, not shoot my neighbor, and pay my taxes. I do all that voluntarily.
EDIT: I don't follow Hacker News' rules and norms because I'm afraid of being banned, but because I respect the other people here, respect that there need to be rules, and respect our hosts' authority and need to make them. It's something (almost) all learn as children; it's healthy social interaction.
Most people are responsible members of their communities. The concept of force applies only to a very few.
> For example, government doesn't force me to obey the law; I do it voluntarily. They don't force me to pay my bills, not shoot my neighbor, and pay my taxes. I do all that voluntarily.
That sounds like the IRS's shtick about income taxes being "voluntary". From a technical perspective, these decisions are under duress, under threat of legal repercussion, even if you find that choice agreeable and would act in the same way without the law involved.
That sounds like the IRS's shtick about income taxes being "voluntary". From a technical perspective, these decisions are under duress, under threat of legal repercussion, even if you find that choice agreeable and would act in the same way without the law involved.
> From a technical perspective
I'm not sure what this means. I'm aware of the theoretical argument.
The great majority obey the law because they want to. The threat of jail is actually minor; you can get away with quite a bit.
I'm not sure what this means. I'm aware of the theoretical argument.
The great majority obey the law because they want to. The threat of jail is actually minor; you can get away with quite a bit.
The concept of force applies only to a very few.
No, it applies to everybody. That you, by happenstance, voluntarily do something that somebody is trying to coerce you into doing does not negate the threat of force.
Your position might change one day when your circumstances change, and then the seemingly benevolent government that you put your faith in may well show its teeth. But those teeth are always lurking, even if they're just out of sight.
No, it applies to everybody. That you, by happenstance, voluntarily do something that somebody is trying to coerce you into doing does not negate the threat of force.
Your position might change one day when your circumstances change, and then the seemingly benevolent government that you put your faith in may well show its teeth. But those teeth are always lurking, even if they're just out of sight.
> For example, government doesn't force me to obey the law; I do it voluntarily. They don't force me to pay my bills, not shoot my neighbor, and pay my taxes. I do all that voluntarily.
Yes you don't do those things because you will be sent to prison. Is it going to be Ok to send Bobby to prison because he didn't want to cover Suzi's medical bill?
Yes you don't do those things because you will be sent to prison. Is it going to be Ok to send Bobby to prison because he didn't want to cover Suzi's medical bill?
> you don't do those things because you will be sent to prison
No, I don't do them because I don't want to, and because I respect group decisions. I want to pay my bills; I don't want to rip off other people. I don't shoot my neighbor because I'm not a sociopath and like normal, healthy people I very much don't want to do it. I pay my taxes because we took a vote and I respect that and want to do my share. etc.
You can get away with a lot and not go to jail. That's not what determines most people's behavior.
No, I don't do them because I don't want to, and because I respect group decisions. I want to pay my bills; I don't want to rip off other people. I don't shoot my neighbor because I'm not a sociopath and like normal, healthy people I very much don't want to do it. I pay my taxes because we took a vote and I respect that and want to do my share. etc.
You can get away with a lot and not go to jail. That's not what determines most people's behavior.
The difficulty here is making health care a profitable business, which is at odds with providing good health care. American health care, even for the wealthy, is a miserable affair when someone really needs major care (such as following a traumatic accident). The patient becomes a liability for the insurance company and a profit center for the hospital, all of which is more important than the patient's long term recovery. That is not the only way American health care fails.
I would definitely welcome a unitified health care system in California.
I would definitely welcome a unitified health care system in California.
> Using force / aggression (aka the government forcing you to do something) is a violation of your most fundamental rights, and strips you of your agency and dignity as a human being.
So you assert, as if this were universally accepted.
I assert being bankrupted or killed for want of affordable, accessible healthcare is a violation of my most fundamental rights, and strips me of agency and dignity as a human being.
So you assert, as if this were universally accepted.
I assert being bankrupted or killed for want of affordable, accessible healthcare is a violation of my most fundamental rights, and strips me of agency and dignity as a human being.
I assert being bankrupted
How is being bankrupted a violation of your rights? If anything, it would seem that it's the opposite, as it's your creditors who lose something that you had committed to repay them, no?
affordable, accessible healthcare
You have the right to purchase as much health-care as you can, based on some balance between what you want and can afford. But on what basis do you assert that the world owes you health-care? In the absence of any other system, would you say that it's OK to stick a gun in the face of a doctor and command her to treat you for free? Are you entitled to medical care to the point that your "right" trumps the rights of others to avoid coercive force?
How is being bankrupted a violation of your rights? If anything, it would seem that it's the opposite, as it's your creditors who lose something that you had committed to repay them, no?
affordable, accessible healthcare
You have the right to purchase as much health-care as you can, based on some balance between what you want and can afford. But on what basis do you assert that the world owes you health-care? In the absence of any other system, would you say that it's OK to stick a gun in the face of a doctor and command her to treat you for free? Are you entitled to medical care to the point that your "right" trumps the rights of others to avoid coercive force?
"Take on this massive debt or you'll die" isn't coercive force?
No, I wouldn't force a doctor to work for free at gunpoint. That's why even single-payer systems pay doctors to willingly work within national healthcare systems.
The rights to life, liberty, and the pursuit of happiness have substantially more historical support here in the US than your asserted right not to be taxed for anything.
No, I wouldn't force a doctor to work for free at gunpoint. That's why even single-payer systems pay doctors to willingly work within national healthcare systems.
The rights to life, liberty, and the pursuit of happiness have substantially more historical support here in the US than your asserted right not to be taxed for anything.
Using force to collect money from citizens and then spending it on their behalf is what governments do. The word for a big organization that works for the common good and gets its money voluntarily is "charity."
> Using force / aggression (aka the government forcing you to do something) is a violation of your most fundamental rights, and strips you of your agency and dignity as a human being.
This premise is not as self evident as you believe.
This premise is not as self evident as you believe.
You must not be familiar with market failures
We are doomed.
Last I checked, single-payer health care in the US is not one of the signs of the apocalypse.
Unless you mean "It's going to be designed by the California legislature, therefore we're doomed to a horrible and expensive failure", in which case, yeah, that seems likely.
Unless you mean "It's going to be designed by the California legislature, therefore we're doomed to a horrible and expensive failure", in which case, yeah, that seems likely.
How so?
This will likely be funded from income tax. As a mid-30s person who earns a decent tech salary and has zero hope of buying a house in the decent parts of the SF Bay area, I think this is another case of taking from the young to feed the old. We should totally do this single-payer thing and pay for it via a wealth tax (that takes the current price of your home into account). Lets make it tiny .. say 0.5% a year.
Repeal Prop 13 for non-residential properties, pay for it with property taxes. Side effect: commercial property is used in a vastly more efficient manner.
Your workplace probably pays $500/month for your health insurance. If the employer has to stop paying that and you pay $500/month in taxes instead, it will be about break even anyway. Or even less, since I more forsee a %1-%2 tax increase vs. the current %4-6+ tax that is health insurance.
I think you're assuming that there won't be over-the-top optional healthcare that we'd all (as in, people w/ good insurance at the moment) have to buy in order to meet the same quality we currently have.
Just going by my experience in Canada, most people don't buy too much extra. You still have to get dental & vision although, but the costs for that are minor. Many don't buy any health insurance at all.
Canadians are also used to a very different level of healthcare. If you can convince a vast chunk of Americans to wait 12+ months for a joint replacement, then yes it could work.
> As a mid-30s person who earns a decent tech salary
... you can afford it. Moreso that others. You _are_ the wealth.
... you can afford it. Moreso that others. You _are_ the wealth.
He can afford it. Others can't. Why should he pay for them just because they have a lower value?
So these 'lower value' people should just die when they get cancer?
I find the idea that not being able to earn a high enough salary means you are unworthy of basic medical care repugnant.
I find the idea that not being able to earn a high enough salary means you are unworthy of basic medical care repugnant.
If you read my post, I said I was in favor of this as long as it doesn't burden income earners. Some degree of health care and education are basic human rights in my opinion.
If you want everyone to have the "Cadillac" health plan and education plan, you need to tell me how society will pay for it? And lets talk sustainable plans .. no more kicking down the can to our kids and grand kids.
Finally, to all the negative commentators on my post, please read up on the difference between wealth and income. At current rents, factoring current child care costs, lack of pensions and existing tax rates, someone who makes 200K in California is worse off than someone who owns a detached house in Mountain View and a few other properties (by virtue of being here from the Orchard days), and then hides his/her income. I've seen too many people like that at this point in my life. Enough is enough.
If you want everyone to have the "Cadillac" health plan and education plan, you need to tell me how society will pay for it? And lets talk sustainable plans .. no more kicking down the can to our kids and grand kids.
Finally, to all the negative commentators on my post, please read up on the difference between wealth and income. At current rents, factoring current child care costs, lack of pensions and existing tax rates, someone who makes 200K in California is worse off than someone who owns a detached house in Mountain View and a few other properties (by virtue of being here from the Orchard days), and then hides his/her income. I've seen too many people like that at this point in my life. Enough is enough.
It depends on how much the people that know how to treat your cancer want to charge and if the hypothetical person with cancer can afford it. Nowhere else in the world do we say "This person can't afford this? Oh well we'll ignore it then. cortesoft finds it repugnant!"
I wouldn't call cancer treatments "basic" by any stretch of the imagination.
I wouldn't call cancer treatments "basic" by any stretch of the imagination.
To be blithe, it goes into the same ultimate goal of social welfare: to keep the not-well-off contented enough to prevent revolution. So he can either pay for programs to improve medical care in general, or he can pay for a militia to protect him should there be a class-based insurrection. That is the pragmatic principle behind taxation.
Why are others entitled to his money?
You are arguing against the fundamentals of taxation.
Why are others entitled to his money (for healthcare)? Because we decided that we are all good people and take care of each other.
Why are others entitled to his money (for healthcare)? Because we decided that we are all good people and take care of each other.
And, it's more humane to pay taxes for social welfare, than it is to pay taxes to soldiers to protect you by shooting the needy who would hang you for not giving social welfare to them.
He is arguing that they are not entitled to his money, but others should be entitled to others (home owners) money. Or as Pink Floyd might say "share it fairly but don't take a slice of my pie"
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I'm in my 30s as well -- I make a great tech salary and own small house that cost me a ton to buy. I pay a lot in taxes. I support a family of four off of my salary.
At the end of the day we basically live the same lifestyle that I grew up with, and my dad was a police officer, my mom a public high school teacher. Our house is smaller than the one I grew up with, the local public schools are about the same quality. I'm not complaining, because I'm staying in the Bay Area for a reason: I believe that my good tech salary can be an amazing tech salary if I build the right skills, climb the right ladders. I think it's a chance for upward mobility. But it's a tough call when I ponder what my life would be like if I took a slightly lesser paying job in a more reasonable area of the country.
So, anyway, my point is that you can make the case that "you can afford it, your fellow Californians deserve it," and I'll roll my eyes because no one makes decisions that way. If I had to pay 10% more each year in taxes, I'd definitely be out of here. The other options are just way better at that point.
So, there's a point where I'm simply going to move instead of pay. You can lecture me about what I ought to do all you like but I have a family to take care of, and our standard of living matters to me. Yes, we'd be fine with less money, but I want even more for my family and I really don't feel bad about it.
At the end of the day we basically live the same lifestyle that I grew up with, and my dad was a police officer, my mom a public high school teacher. Our house is smaller than the one I grew up with, the local public schools are about the same quality. I'm not complaining, because I'm staying in the Bay Area for a reason: I believe that my good tech salary can be an amazing tech salary if I build the right skills, climb the right ladders. I think it's a chance for upward mobility. But it's a tough call when I ponder what my life would be like if I took a slightly lesser paying job in a more reasonable area of the country.
So, anyway, my point is that you can make the case that "you can afford it, your fellow Californians deserve it," and I'll roll my eyes because no one makes decisions that way. If I had to pay 10% more each year in taxes, I'd definitely be out of here. The other options are just way better at that point.
So, there's a point where I'm simply going to move instead of pay. You can lecture me about what I ought to do all you like but I have a family to take care of, and our standard of living matters to me. Yes, we'd be fine with less money, but I want even more for my family and I really don't feel bad about it.
That's fine, you can join the exodus of Californians in Austin or Boulder or Portland who didn't own real estate but couldn't afford to live here either.
Why?
Because for hundreds of years collectivism has been accelerating and it's become nearly, if not entirely, out of control at this point.
Ah yes, "collectivism." What you call that, the masses of humanity call civilization.
Exactly, that's the problem.
No man is an island, but if you want to try, there's still wilderness out there to build utopian Galt's Gulches without even having to seastead.
Yes, we're working on it. https://www.youtube.com/watch?v=cOubCHLXT6A
Enjoy your right of exit!
Serious question: what do you propose we do with the people dying in the street?
Make them move out of the streets and into the country.
That's the entire plan? Drop them off in the forest and drive off? There's a bit more to homelessness and surviving in the country.
So... are you one of the "Freemen on the land"?
No.
Ok so I am curious about the "collectivism" story. I mean, we as species have been talking care of our elderly and injured for like what, 50,000 years or 100,000 years or whatever? Seems to be working well.
And, if we all chip in, we can have nice things. Roads, water, electricity, museums, libraries, courts, police, etc.
Is that bad?
And, if we all chip in, we can have nice things. Roads, water, electricity, museums, libraries, courts, police, etc.
Is that bad?
If it's voluntary absolutely not. But when people fetishize collectivism the natural result is forced collectivism, which is just a rationalization of theft, robbery, and usually murder. That is bad.
Now tell us what you think of taxes or public education.
My thoughts: I benefit from your children being educated on my dime. You and I benefit from infrastructure we both use maintained on our dime. It's not theft, robbery, murder, or bad or fetishize collectivism.
My thoughts: I benefit from your children being educated on my dime. You and I benefit from infrastructure we both use maintained on our dime. It's not theft, robbery, murder, or bad or fetishize collectivism.
"forced collectivism". Ok, I guess you are from China. Did you experience theft, robbery and murder?
Theft and robbery certainly. But obviously I have not been murdered which is nice. Luckier than manyl