California considers a single-payer, universal health care plan | Hacker News Reader

California considers a single-payer, universal health care plan

mercurynews.com

The article mentions the Canadian health care system, which I can speak of, since I live in Canada.

In Canada, most health care is paid for by provincially funded systems which pay health care providers directly. Here in Ontario, our system is called OHIP. Canada also places limits on drug prices.

The system is mostly working. If you need routine or critical care, you get it. But there are some issues. If you need expensive medical care for a condition that isn't killing you right now -- hip replacements are the common example here -- you can expect to wait quite a while because only so many treatments are funded every year. Some people who have such conditions do travel abroad to have them fixed, at their own expense, but that is quite rare. Not a lot of people can fork over the six-figure sums for such treatments out of pocket. I suppose if things started fraying, people would start buying US medical insurance, but we're definitely not at that point now.

Also, it can be quite hard to get a family physician in small and midsize towns, because few physicians want to locate there. When I lived in Kitchener, I called around to some physicians, and they all had one-to-two-year waiting lists. Fortunately there are plenty of walk-in medical centres, which are staffed by physicians, and there they'll see you right away.

Generally, my sense is that the Canadian system is working, but there are some issues.

Fellow Ontarian who thinks OHIP (ontario health insurance plan) is a pretty good system overall. One thing that seems to keep everything in balance is the regions (think counties in America) run the hospitals and most doctors run their own practices. The province just pays the bills, which mostly reduces the conflicts of interest. Too much landing at any one level of government is a recipe for things to get neglected.

As johan_larson points out, the weakest part of the Canadian system is elective, quality of life procedures. If you need emergency or urgent care you get it, but if a new hip or knee could really change your life the waiting list can be long. When my dad nearly ripped his finger off the hospital stitched him up right away, but it was nearly a year before he saw a plastic surgeon to clean up the scar and help get some mobility back in the finger. Shorter wait times would be great, but I will take it over medical bankruptcy and ever rising insurance premiums like in the US. No one should ever have to decide between medical coverage and other necessities like shelter or food.

A argument proponents of single payer health care never seem to focus on enough is it's better economics, both at the macro and micro levels. At a province/state level, having a single payer means huge leverage when negotiating prices. Medical staff deserve to be properly compensated for their highly skilled labour, but having a fixed fee schedule for a procedure works wonders for eliminating waste. Single payer also pools risk across the broadest possible population. All the perfectly healthy 25-45 year olds pay for the care of the very young, very old, and very ill. Private insurance won't ever get that large a pool, so the premiums have to be higher to justify the business. At the personal level, single payer health care is amazingly freeing. With health coverage no longer tied to employment it's much easier for people to take a risk on themselves and start a small business. Or work for a small business that wouldn't be able to afford to offer insurance themselves. It's better for business as well, since the cost and complexity of offering health care is no longer on the books. I almost never hear single payer fans paint opponents as anti-business and they really should; single payer is great for everyone who isn't a medical middle man.

" it can be quite hard to get a family physician"

In Waterloo Ontario, I was unable to get a doctor.

The Ont. Gov's policy has been push people into clinics, wherein they don't have your records, and they don't take a 'long term approach'.

I had a situation that was difficult to diagnose - nobody could help me.

It's against the law in Canada to pay for services, I was in a very desperate quandary and my health was at stake.

I was eventually able to get into the 'Cleveland Clinic' in Toronto - an American firm - that finds some ways around the system.

The Ontario system is also hurting quite badly from inefficiencies.

Most European systems allow for some degree of private insurance, and that should be the direction Canada moves in - as a matter of civil rights, as a matter of economic opportunity, but also to perhaps help the public system itself 'learn from' the private operations.

Yes - the Ontario system 'covers everyone' but it has problems.

Politically, I don't think this will win in California.

I significantly doubt that most Californians who actually have 'good but overly-expensive' coverage will support universal coverage.

There are tons of opportunities for efficiencies - like requiring that hospitals bill the 'same price for the same service' to everyone. Among other things.

It'd be great if they tried some of the more obvious things before they go 'full on universal'.

It's disappointing that you can't buy some top-up insurance that lets you avoid excessive wait time, but the wait times don't seem crazy[0], especially if they're triaging people to do the most urgent cases first. Though supposedly these stats don't capture the full picture and wait times are longer for some patients [1].

The only real explanations I could come up with off the top of my head for why wait times should even exist are that hip replacements are highly seasonal, turns out there was a study done on this a decade ago [2], and a little surprisingly there is a pretty large seasonality in service delivery; i.e. doctors take holidays/people don't want to have surgery during the holidays and the people needing surgery back up. Though it didn't talk about whether demand is also seasonal and how that affects things. But since the wait times are still long it seems like nothing has really been done to address this.

Still, this seems like a solvable problem. In fact it looks like the national statistics are obscuring the fact that wait times are highly variable with some provinces doing significantly better [3]

[0] http://waittimes.cihi.ca/All

[1] http://montrealgazette.com/news/local-news/new-report-shows-...

[2] http://bmchealthservres.biomedcentral.com/articles/10.1186/1...

[3] http://www.huffingtonpost.ca/rob-brown/wait-times-hip-surger...

A hip replacement seems like it would be closer to $30,000. Still not particularly affordable, but a lot less than $100,000.

http://www.nytimes.com/2013/08/04/health/for-medical-tourist...

I guess for someone ~60, 3 years of US health insurance would be in the ballpark.

Edit: Here's a place located in the US that is specializing in medical tourism, estimated $25,000 for the hip replacement procedure: https://surgerycenterok.com/?procedure_category=hip#jump

That isn't the total cost, it doesn't include imaging and stuff. But that won't be $75,000 either.

The USA really needs a base level of health insurance, private can fill the gap on top IMO. It needs to cover the basics and only proven treatments.

Medicare For Everybody would solve some problems, no doubt. I expect the opposition comes from the right, who are worried that the initial program, no matter how modest, would be the thin end of the wedge that eventually leads to the complete socialization of American medicine.

They simply don't want to pay for it.

They talk about personal freedom and stuff, but they just mean they don't want to pay for it.

You've described a system wherein waiting lists are pervasive. Why do you think it's working?

(This doesn't imply I think the American system is working. On the contrary, I think it's a mess.)

"Pervasive" sounds like an overstatement. Most conditions don't have waiting lists. But a few do.

In the medical field, I don't think it's possible to give people everything they want, because some people want everything done to keep them alive but some treatments are horrendously expensive. Any funding system is therefore going to have some sort of shortfall; someone isn't going to get everything they want. The best that can realistically be done is to ensure that the shortfalls between want and get are never too severe, and are generally distributed in some fair and sensible way. As far as I can tell, the Canadian system meets those criteria.

To be clear, I do think the Canadian system could be improved. To give just one example, I think it should be legal to pay for your own medical procedures out of pocket. If you have the funds to pay the full freight, who are we to stop you? But that would mean a two-tier system, one for the rich and one for the rest of us, which is currently politically unacceptable in Canada.

" Most conditions don't have waiting lists. But a few do."

Almost all conditions have delays that are considerably longer than other systems.

Just getting to see a specialist for something benign can take months.

If you have highly specialized needs (such as a sports injury) - it can be very problematic.

"I think it should be legal to pay for your own medical procedures out of pocket. "

Some degree of privatization would be a good start.

I suppose it's better than getting rejected for treatment. Or having a huge out-of-pocket co-pay. Or having to fight each bill that comes through that claims insufficient coverage--a single hospital stay a while back resulted in 42 separate bills!

Look, with a limited supply of money, care will always be rationed at some point. Rationing hip replacements so that truly urgent healthcare can be administered with less rationing seems to me to be a better alternative to the US system, where even people with "good" healthcare coverage end up going bankrupt when dealing with severe illness.

Waitlists are a red herring. It'll take 3-6 months here too. people over 65 get them, that's all Medicare. Even if it was regular insurance you'd still see waitlists for the doctors due to demand.

In general money makes the world go round. It takes a lot of very smart people working very hard to innovate. That's only going to happen when there is a lot of money. So I'm not against profit in the medics industry. Without profit, I think cures would come out much slower becuase smart people would move to make money elsewhere.

It stinks that health care is so expensive. But by moving to a single payer system, innovation will be stifled. Temporarily that may be fine, but it's like killing the goose that lays the golden egg. Innovation will slow and in maybe 10 years we will be worse off than we were before

You could make the argument that continued easy profits stifle innovation just as easily. Until you have data to support the correlation, I think the default of not overpaying for basic medical services is orders of magnitude more important of an issue.

It seems that you are suggesting that the profits made by insurance companies is the key factor funding innovation in health care. This might be worth looking into, but I doubt this is true. It seems just as plausible if not more so that government grants in a country with single payer health care would drive innovation. The government would have an interest in both improving the health of citizens and finding new methods/techniques that reduce the cost of diagnosis and treatment.

The usual argument is that single payer will be cheaper because the single payer has a strong negotiating position from which to pay doctors and drug companies less. The suggestion is that the profits made by drug companies are a key factor in innovating health care.

The only people who seem to be saying this are the insurance companies who would be hurt the most. And I think that even if this were true, you're leaving out the opportunity for innovation in other fields which are stymied by people who are too scared to leave a job with secure insurance to go on their own. This was one of the huge benefits to ACA even, and that plan still had alot of tradeoffs.

If America is moving more toward a "gig" economy, we are going to require a healthcare system that is no longer tied to a single job to make it work.

Good. It'll be even better if multiple states decide to pool together and go single payer as well.

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