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Comment by throwaway13337 | Hacker News Reader

"The UBI is to be financed by getting rid of Social Security, Medicare, Medicaid, food stamps, Supplemental Security Income, housing subsidies, welfare for single women and every other kind of welfare and social-services program, as well as agricultural subsidies and corporate welfare."

How the hell does that happen politically?

I would love to see basic income replacing a large portion of social programs in the states but no one seems to be talking about how we get from where we are to where we want to be, realistically.

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The thing is, I don't think it can happen politically. What is going on now is just the research stage so that we have some sort of data point for UBI supporters to latch onto.

There are all sorts of groups inside the UBI tent, and many of them disagree with each other violently, but we're so far from a UBI that for now, everyone can agree on it in the broadest possible way.

I, personally, have a completely different take on all of this from most UBI'ers. I take the long view: in 50 years, physical labor could be eliminated. WTF do we do when this happens? Do we relegate half of society to be homeless? Or do we begin the slow march towards eliminating work altogether.

Few talk about this scenario, and those that do often tack on "... and then Skynet takes over and robots enslave us all." Yet, it's still a very valid discussion to be having. I think all this UBI research and interest is in furtherance of the elimination of work, altogether. That's not something that will happen over night, or even in 10 years, but in order for it to happen, humanity needs to begin gathering the data points necessary to enact a solution to the end of work problem.

In the short term, this would eliminate social safety nets, but let's be honest, this is NEVER going to happen in America without a revolution of some kind. Whenever that happens, hopefully the UBI research will be far enough along to support a movement to enact it.

I fear the question will be answered with some very dark times. Indeed what will people do, when most of them aren't actually "necessary", and what will they agree to, given that most of them will also be driven by fear of becoming one of those unnecessary ones?

As things stands, politically, and culturally, it's more likely to become som dystopian story of cleansing. Walled communities of elites keeping the poor outside of civilized society, and perhaps even death camps.

So I really do hope that we, along the way, not only get data on the economics of it, but also a new ethical mainstream regarding entitlement. Capitalism will be a rather dangerous as framework of ethics in a world where economic value is derived entirely from capital. Only the elite can justify their existance on that framework.

I'm currently aligned with the geo-libertarian view of things, as an example of a dissenting UBI-proponent. It seems the "mainstream" UBI thinking at the moment is rather socialistic in nature. Don't really see how that can fare much better than the capitalistic views when faced with the proposition that 10% is supposed to pay for the other 90%

>I, personally, have a completely different take on all of this from most UBI'ers. I take the long view: in 50 years, physical labor could be eliminated. WTF do we do when this happens? Do we relegate half of society to be homeless?

Just because you can't imagine what people will do after physical labor is antiquated doesn't mean the average person, who you underestimate as a bumbling fool, will not come up with ways to earn an income.

This is how I feel. A lot of people don't even think about this problem. Cost of living increasing with robots taking more and more nominal jobs that the lower class occupies the homeless rate is going to soar in the future. We are already seeing computers take lots of jobs due to the minimal pay increases in several states.

A basic income is going to be the way of life or people are going to have to deal with millions of poor and an increase in crime.

One of the things that bothers me about the saying, "I don't want to pay for all their stuff, I work hard." Is that people don't realize one of the reasons your able to work hard and not worry about your house getting robbed while your at work is that we take care of the poor and disabled. If you take away that care in the future because your too greedy to help out your fellow man, then you end up losing a lot of peace of mind as crime increases because of people having to steal for basic necessities.

Yeah, it won't. The $10,000 left after the mandatory health payments would be a cut for many social security recipients, and many of those same people are also probably getting more than $3,000 a year in health care out of Medicare.

Similar problems with Medicaid, it's worth a lot more than $3,000 to the people that are getting it (mostly because children).

This is basically taking the desire to cut entitlement programs and rephrasing it to take advantage of the attention basic income is getting these days.

I sort of expect the best thing the US can do right now to make life better and cheaper for the average citizen is to create/fund residency programs. More doctors will actually lead to lower prices. Pouring money into the demand side won't.

Not only will the voting public oppose many of these cuts, corporations (and lobbying groups representing professionals such as doctors, or AARP) will oppose them. And the latter is more ominous to me since they have the lobbying muscle in place.

>create/fund residency programs

Don't several medical lobbying groups actively coerce the government to limit the number of new doctors that can be minted, both overall and in given areas of practice? I am not optimistic about this given the lobbying groups' strong track record of protecting and furthering their self interest.

If the public at large tells those lobbies to go screw, Congress will listen.

So start talking about how we need more doctors in the US.

> Don't several medical lobbying groups actively coerce the government to limit the number of new doctors that can be minted, both overall and in given areas of practice?

Not really. The AMA is often blamed for limiting the number of medical school slots available, but they have nothing to do with that - it's capped by the AAMC, which has been very deliberately raising the number of medical school positions in the US for over a decade now.

But even if that cap were lifted altogether, the number of practicing physicians would be completely unaffected, because we already have more MDs than we have residency slots available. Increasing residency programs would require funding, and currently Medicare is the source of funds for residency programs. Hospitals would typically make a loss on residency programs otherwise; contrary to what some people believe, they're actually quite expensive to operate.

>...Hospitals would typically make a loss on residency programs otherwise; contrary to what some people believe, they're actually quite expensive to operate.

How does that work? Residents make very little money and do a lot of work. How are they not a profit center for hospitals?

> Residents make very little money and do a lot of work. How are they not a profit center for hospitals?

Residents start their first year knowing literally nothing about practicing medicine. Medical school teaches the foundation, but you learn the practice during residency. In addition, the ratio of attending physicians to residents is capped by law (i believe it's 3:1).

Would a startup want to hire three fresh-out-of-high-school interns for every full-time employee? I can't think of any company that does this. At some point they'd get up to speed, yes, but in the short term they'd be a huge drag.

>Residents start their first year knowing literally nothing about practicing medicine.

If this is true, it really indicates that how we train medical practitioners needs to be reformed. (If true, maybe there should be different programs for people wanting to become medical researchers vs those who treat patients.)

>In addition, the ratio of attending physicians to residents is capped by law (i believe it's 3:1).

Are hospitals actually at that 3:1 ratio? The AAMC seems to be saying the limiting factor right now is the limits on medicare subsidies for residents: https://www.aamc.org/advocacy/gme/71178/gme_gme0012.html

>...Would a startup want to hire three fresh-out-of-high-school interns for every full-time employee?

Probably closer would be companies hiring engineering students straight out of college. Those college projects the students did generally aren’t anything like the work they will be doing. Companies don’t hire at a 3 to 1 ratio, but they do hire them and they pay them more than residents get paid and don’t get subsidies from the government to do so.

I was originally replying to your comment: >...Hospitals would typically make a loss on residency programs otherwise; contrary to what some people believe, they're actually quite expensive to operate.

Thinking about it, I guess if hospitals don’t bill patients for work done by residents, then they would obviously need to paid by the government (or someone else) but I don’t know if that is how it works.

> More doctors will actually lead to lower prices

It might if we had a free market for healthcare and if providers were the largest healthcare expense. But we don't, and they're not. Providers' take-home pay only amounts to about 10% of healthcare spending nationally[0].

Furthermore, the reason we don't have a competitive market is entirely due to the payer situation, not the providers. Providers (particularly hospitals, who account for a much larger chunk of spending) can't offer transparent pricing, because their cost structures are needlessly complex. I've written about this elsewhere, but in short, Medicare is not required to cover the direct costs[1] of the care that their patients receive in the reimbursements that they issue. This means that providers have to make up the difference in their contracts with private insurers, which is why they can't tell you how much a particular procedure will cost you - they really don't know, because it's not purely a function of what it costs them to treat that particular patient.

[0] http://economix.blogs.nytimes.com/2008/11/14/do-doctors-sala...

[1] I'm referring to COGS - the marginal cost per patient, which excludes markup and overhead.

I dunno, I think if there were more doctors more of them would end up working outside of hospitals.

It's certainly the case around here that doctors are moving under the hospital umbrella.

This means that providers have to make up the difference in their contracts with private insurers, which is why they can't tell you how much a particular procedure will cost you - they really don't know, because it has nothing to do with what it costs them.

Yes, this is an obnoxious tax. I don't think the hospitals are forced to keep their prices obscure though (see Massachusetts or Oklahoma), it just happens to be the best way for them to make revenue because if people could easily shop prices, they would. Another component of the problem are the many people who have a plan where they simply don't care about prices because they have a low out of pocket limit.

> It's certainly the case around here that doctors are moving under the hospital umbrella.

That's part of a trend that's a few decades old, and which has accelerated in the last 5-10 years. It's not a function of the number of physicians; physicians are selling their practices to hospitals because they can no longer sustain themselves in private practice.

> I don't think the hospitals are forced to keep their prices obscure though (see Massachusetts or Oklahoma), it just happens to be the best way for them to make revenue because if people could easily shop prices, they would.

If anything, hospitals would prefer to be able to compete this way directly. They can't, though, because there is no single 'price', even if you're talking about a discrete, routine procedure that has no risk for complications. The way medical billing works, they don't necessarily have a set price for a given service per carrier. And even if they do, that doesn't always correlate to what the patient ends up paying (which is, of course, the thing the patient actually cares about). The reason they don't have a set price - even internally - isn't because they don't want to. It's because the contracts with public and private insurers have resulted in the amount of money they need to charge for a service being a function of so many external factors that they literally can't.

Chapter 224 is a perfect example of a feel-good law that doesn't actually do anything in practice, because it fails to address the underlying complexity that's the root of the current problem with price transparency.

From what I understand, they often have no idea what services cost. This is different than not having an internal price. And there shouldn't be external factors that prevent them from measuring it.

Or are you saying that they are contractually bound to avoid tracking costs?

I don't know the answer to your question, but here's an interesting anecdote: https://news.ycombinator.com/item?id=4465845

Right, they aren't setup to bill the damn thing. It's ridiculous.

chimeracoder seems to be saying that this is because of the complexity that comes from interacting with insurance companies and the public payers. Where I don't really buy that explanation is where there is in fact a fixed capital cost associated with the machine, and a certain number of uses of the machine per year, and a pretty fixed level of complexity per use (different scans will take a different amount of time, but each type of scan will be reasonably consistent from patient to patient). So they can take a spreadsheet and put in the capital costs and the operating costs and the staffing costs and boom, they have a ballpark figure for what each scan costs. It won't be the exact number for a given scan, but it will be closer than not having any estimate at all. I don't see where complexity on the billing side prevents them from doing what I describe.

Are salaries a good measure of the income of doctors? I've read that more than half of doctors are self employed, and I suspect that their ownership stake in medical businesses produces a good portion of their incomes.

It's the other way around. As of recently, the majority of doctors are salaried (employed), not in private practice.

The numbers I cite correspond to the practice revenues, but as much as half of what doctors in private practice receive in reimbursements goes to practice expenses and insurance.

That's an interesting change. It wasn't too many years ago that my employer-provided health insurance was through a doctor-owned provider.

> The $10,000 left after the mandatory health payments would be a cut for many social security recipients

The easy way to do this is to give people a one-time election between social security and the basic income, so that nobody can object that they're not better off. Anybody who isn't at or close to retirement will choose the basic income because it begins paying immediately, the lifetime payments are higher and they wouldn't have to pay social security tax anymore. Then in 20 years or so there would be no one left on social security and it could be discontinued.

> Similar problems with Medicaid, it's worth a lot more than $3,000 to the people that are getting it (mostly because children).

It seems like your argument is that we can't do it because there are a relatively small number of people who would be better off under the existing system. But by that logic we could never change anything, even if the net benefits are very large, as long as there is anyone who is better off under the status quo.

> It seems like your argument is that we can't do it because there are a relatively small number of people who would be better off under the existing system. But by that logic we could never change anything, even if the net benefits are very large, as long as there is anyone who is better off under the status quo.

I think this is an incredibly unfair and callous assessment of what's going on with catastrophic health care coverage. It's not about "the relatively small number of people who would be better off under the existing system." It's about the relatively small number people who are alive under the existing system who would be dead under the proposed one.

The UBI proposal in the article (one I find pretty weak, and I'm a huge proponent of UBI) is that you're getting $10k plus healthcare. So there's that.

But.

There is no part of the proposal that covers making sure coverage is equal in value to Medicare - in a private market I'm betting benefits start getting cut post-haste. UBI without universal healthcare is a nightmare, and is all but privatizing Medicare. Surprise!

Also, since children under 18 don't get UBI, they would have to be covered by their parents' $3k/annual buy. But again, privatized "universal" healthcare? No thanks.

That's actually an incredibly short-sighted risk calculation that intentionally weighs some unknowns as higher value than others.

For example, I can make the same kind of argument in the opposite direction: if UBI creates a disincentive within inner cities for fewer kids to become drug dealers, which creates less opportunities for violence, leading to significantly less deaths in the inner city, I think that you are making "an incredibly unfair and callous assessment" as well.

Saying that any plan that transfers risk from the current state to a different state that is potentially net better for all is to miss the point that we've already chosen a system that disadvantages SOMEONE... and to change it will probably disadvantage someone different.

We do not live in some Vulcan dystopia. The idea of essentially telling people, who are currently alive, "Yes, we can keep you alive, but by letting you die, there is some probability (which we don't really know and are just guessing at) that we can use the saved money to prevent 1.2 deaths" strikes me as the plot of a horror science fiction movie.

I am all for UBI, but like another poster said I don't think it works without universal health care if you get rid of all the other current transfer payments. It seems the author of the article agrees, but I don't see how the 3K for insurance makes the numbers add up.

> The idea of essentially telling people, who are currently alive, "Yes, we can keep you alive, but by letting you die, there is some probability (which we don't really know and are just guessing at) that we can use the saved money to prevent 1.2 deaths" strikes me as the plot of a horror science fiction movie.

People hate having to make that choice. Hate it. But that doesn't make it go away. We could make cars safer in well-known obvious ways, but they would be more expensive and use more fuel. Many, many, many lives would be saved if we immediately stopped burning coal, but electricity would be more expensive, and then maybe some people would freeze to death because they can't afford heat, or because they became unemployed and lost medical coverage. And in some cases we may even be getting it wrong, but that doesn't get you out of having to make a hard decision.

We can have either basic income or open borders/mass immigration -- but I don't see how we can have both.

Any UBI plan would need to require some form of citizenship verification. E-verify to get your 13k. We could then dial up or dial down the number of naturalized citizens per year to make the UBI program sustainable.

I think it is better to have eg Canada/US do it at the same time.

What if they just said "ok everyone born before 2017 will get the old system (social security, etc), and everyone born in 2017 or later will get the new system. This way everyone alive and voting isn't losing anything they were expecting before. There would be a period of 80-100 years during which both systems are intact, but this somewhat inefficient period would end, leaving only the basic income system.

Regarding social security, that's good; it removes the entire AARP membership as no-voters. You could actually finesse it a bit by saying that anyone born after 2000 (so, turning 18 in 2018) will not be charged FICA when employed, and will not be eligible for SS when they retire -- AND anyone born after 1990 (or perhaps even earlier?) can also opt out, stop paying FICA, start getting BI, and get a tax credit good for their FICA payments to date. Retirees would stop entering the SS system in 2065 and the last survivors would finally die around 2101. The SS system would have to be funded for the rest of the century but for a declining number of beneficiaries.

The other many, many forms of social payments and supplements need individual consideration. It's not all "welfare"; one small example that occurs to me is seriously handicapped (paraplegic, e.g.) people getting financial assistance to cover in-home care. Would the proposed BI adequately cover that? If it wouldn't, this small set of people would be significantly worse off.

UBI isn't a plausible replacement for those, because extreme medical care, and care for the disabled, is priced so far out of range with the rest. I expect part of the steps towards UBI to involve further evolution of our systems for allocating those resources.

But insurance for those isn't.

Just checked healthsherpa plan prices for a 64-year-old, and it came to almost $900/mo with a $5000 deductible. Maybe it's possible to radically reduce healthcare costs, but we should probably do that first before eliminating Medicare.

The problem is eliminating Medicare is essentially a prerequisite to meaningfully reducing healthcare costs. As long as there is a deep pocket to pay whatever outrageous prices people are charged, people will keep getting charged outrageous prices. Take away the money and the price would come down in a hurry.

Is it really Medicare, or medical insurance in general?

What you would need to solve this is socialized medical care supervised by the government, who takes from those who can contribute and gives to those who are in need. It wouldn't have to be completely run by the government but would have to be supervised by it.

> Is it really Medicare, or medical insurance in general?

Medical insurance that works like Medicare obviously has the same problems. But imagine medical insurance where, instead of paying obscene premiums with a low deductible, you pay very low premiums with a deductible of several thousand dollars after which the insurance pays 80%. So if you get cancer you don't die of poverty but for pretty much anything else you're paying out of pocket, i.e. medical insurance, not a payment plan that hides true costs from everybody.

Now the thing that costs $10,000 in one place and $4,000 in the other place is a difference you care about, so you pay the $4,000 (and so does everybody else), causing total medical costs to fall. You also eliminate all the insurance paperwork in any year you don't blow the deductible, allowing doctors to lower their own costs significantly.

However, this leave people still exposed to diseases where the thing that maybe helps you does not cost $10,000 but $100,000 (not uncommon) or $1,000,000.

For instance, recently I read about carfilzomib or sipuleucel, both cancer medicines; $100,000 doesn't get you there yet.

The only reason they can charge $100,000 is that there is a deep pocket to pay for it. It does not cost that much to manufacture the drug. It might cost that much to do the research, but if you want taxpayer funded research then do taxpayer funded research. There is no reason to launder the research subsidy through seven layers of bureaucracy.

The cost and structure of US healthcare is rather a different problem, although potentially both have to be solved to make it work there. In Europe health insurance in many countries is 100-200/month with a few hundred in deductible.

Consider someone at the edges of the distribution of healthiness: say, someone born with severe mental and physical disabilities. A universal basic income will never take sufficient care of this person; his or her medical care will cost much much more than average, and there will be medically necessary non-medical care as well. I think we'd like to socialize those costs, using something like SSDI.

You get there by talking about it, and persuading people about it. There is no magical easy to way to bring about social change unless its profitable. And I'm not sure there are enough landlords foaming at the mouth for the legitimately juicy prospect of tenants with guaranteed paychecks to pay rent to push the issue against the tide of establishment profiteering resistance.

But rather than talk about it on HN (like this) talk about it on Facebook or when talking to friends and family IRL. That is how you actually spread these ideas.

The consequences of making this change are huge and IMHO hard to fully predict - or at least it's hard to have a meaningful debate about what the impact could be. Walmart for example could have a disaster on their hands - a whole swath of jobs no one really wants to do could quickly find themselves lacking staff. And that's just one example

I mostly agree. A few people would stick around to get the check and BI, but a lot of people would just say "Take this job and shove it!"

The Walmart example is a great one of why UBI is a good idea, though. Today they only have employees exclusively due to the "work or die" negotiation position of the workers there. With a UBI, Walmart will only have people filling positions when they offer wages that, at market value, justify the work being done.

Which would also coincidentally mean treating your employees better lets you pay them less, which sounds like a desirable natural motivating force in an economy.

I do not think anyone would argue UBI would not cause a dramatic shift in everything, and as a result the only way to really implement it is slowly - IE, you start people on small cash payments per month, and scale it up to (by most examples) the poverty level over the course of years or even a decade. That way, everyone has plenty of time to react to the economic consequences without a panic, in much the same way states are raising the minimum wage to $15 over 5 years.

Can anyone explain what planets would have to align for a UBI to replace all of these programs?

States will probably have to be allowed to opt-out of the current system, and then implement their own version.

It doesn't.

I suspect this is poisoning the well.

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