Healthy California Act: proposal to make findings about single-payer healthcare

Single-payer is wonderful, and I believe an absolute necessity as we march towards a future of automation and enormous economic inequality.

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.

Every other first world country?

https://en.wikipedia.org/wiki/List_of_countries_with_univers...

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...

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).

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.

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.

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'.

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).

Uh, you could just buy insurance yourself. It's not like no-ones covered unless the State writes the check. smh

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?

  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?

https://wallethub.com/edu/states-with-highest-lowest-tax-bur...

The trick is whether the transition to a single payer system is feasible. Both in terms of taxes, and existing organizations and incentives.

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

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.

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...

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...

Ok, fine, create a public option. But don't force me to buy it. Let me buy my own healthcare.

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.

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

  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...

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.

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.

Thus far I have been able to resist the tempation to do so.

http://www.latimes.com/politics/la-pol-sac-jerry-brown-budge...

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.

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.

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.

The question is, why wouldn't a society or community want universal healthcare for it's people?

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.

“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).”

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.

I can't imagine that insurance not being available for purchase across state lines is helping here, either.

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".

>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.

Ummm... you do realize that many other countries with universal coverage rely on private insurance, right?

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.

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).

What do drug prices have to do with the cost of an office consultation?

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.

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.

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.

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.

(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...

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.

Bureaucrats don't work for free.

It's a huge net loss. Not to mention the fallout from stolen SSNs and creating demand for stolen SSNs

That they are required to treat is even worse for a budget it wouldnt hold long.

Danes aside, are you saying that single payer healthcare would convince Californians to be more conservative towards entrepreneurship?

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.

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.

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.

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.

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.

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.

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.

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?

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?

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.

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, that is not my worldview, not in the slightest.