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Comment by TheSageMage | Hacker News Reader

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?

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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.

Australia did it. It won't happen overnight, but the planning has to start somewhere.

"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).

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.

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.

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.

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.

That's GDP per capita. CA is the largest state in terms of overall GDP.

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.

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.

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.

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 ?

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.

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.

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