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Comment by mmanfrin | Hacker News Reader

[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.

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  California has had a bumper crop in terms of tax revenue

... but is outspending even that! There was a "surprise" extra $1.9 billion deficit hit from Medi-Cal last fiscal year[0] (which should tell you something about the government's inability to track or control spending), and an overall budget deficit is projected for the current year.

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...

> 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...

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...

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...

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.

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.

>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.

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.

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.

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.

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.

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.

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

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!

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...

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.

> 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

  Doesn't 70% of CA tax revenue go towards paying pension obligations

Not even close. The article linked by the comment I replied to states that CA will chip in $5.4bil -- last years budget was $122bil.

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

> 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.

>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.

most likely what will happen is people will just leave CA, leaving a shortage and it will fail

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.

> 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.

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.

> 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.

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.

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.

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.

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...

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 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".

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.

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.

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.

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...

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.

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.

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.

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.

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.

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.

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...

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.

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.

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.

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.

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...

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.

You're just one serious illness or layoff from being one of "those people"

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.

Let's not do the thing where everyone you disagree with is a troll, mmkay?

> 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

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

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.

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...

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.

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.

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.

> 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.

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.

You already subsidise healthcare.

The US government spends more per capita on health than the UK government does.

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