What Killed Single-Payer in California?
newrepublic.com
newrepublic.com
Ultimately I imagine it boils down to voters in a state with already very high taxes (by American standards) being very wary of voting to significantly increasing their taxes again.
In general that's true, but in healthcare it's not. As a percentage of GDP, the US spends as much taxpayer money as the UK, but clearly gets far less for it - the NHS vs. Medicaid, Medicare and other limited programs. I suppose the problem is that states would have to set up a parallel system with costs on top of the existing federal structures, which as you say would be expensive.
If the government provides blanket insurance and it's being delivered by private providers, there's nothing to control costs. This is the exact problem with government educational loans. Society can't control the costs of tuition so costs balloon. And the costs are ballooning because of stupid things like fancy dorm rooms and expensive sporting facilities.
You walk into many hospitals and they look more like a luxury hotel these days. That and all the administrative staff and the fact the hospitals are private and need to turn profits and compete against each other.
And I don't really feel like I'm getting my money's worth from my private employer-provided health insurance either. I am fortunate to be relatively healthy in my middle-age so I go see the doctor once a year, they weigh me, take some blood samples and send me on my way. So I pay an entire year for that. I have no expectations that anything positive or proactive is really going to come out of my "health care." I ended up diagnosing my father's Parkinson's and I see him less frequently each year than his doctor.
So mass private insurance and mass private health care providers seems completely inefficient and a screwed up way to try to properly provide healthcare within a rational cost framework. I want my fellow Americans insured and I want my health care providers freed up to focus on providing health care.
People who work in insurance can get retrained for something else.
But it is in no way as complicated and inconvenient as people in the US seem to think. I can go directly to a specialist in the private sector at short notice and pay out of pocket if I like. That costs about 100 dollars. If I need to go frequently I can simple buy extra private health insurance which doesn't cost a lot, since they don't have to cover all that much given that they can utilize the existing public health care. Lots of companies already offer this in Norway.
Anyway then you typically visit your GP to get a referral but that is done very quickly, and is really just a formality. I can go the same day and spent a couple of minutes to do that. Then I can go to a specialist covered by my private insurance on short notice.
I think the private/public divide we got in Norway works quite well. Public health care usually handles well most health care needs in a timely fashion and with good quality. The problem is usually things like elective surgery where there can be long waiting times. But these cases are handled quite well by the private sector. You can pay for private health insurance to handle those cases. That is cheap because there are really just clinics open from 9 to 5, which does surgery, then transport you to a public hospital for recovery afterwards. That makes their operations cheap as they don't need to be open 24/7 and don't need their own emergency care, ambulances etc. All that is handled by the public sector.
What do you think single-payer is? There's no such thing as "out of network".
I have an expensive employer-provided plan. I can, without any referral, make an appointment with a specialist (surely making $300K+) at a top teaching hospital and expect to wait weeks at the most.
There is no way to offer that level of service to anyone and not explode costs, let alone contain them.
I don't think single-payer works the way you seem to think it does.
> I have an expensive employer-provided plan.
I'm happy for you. What happens when you lose your job?
I live in Belgium. I'm covered by the basic social security health insurance, just like any other Belgian.
> I can, without any referral, make an appointment with a specialist (surely making $300K+) at a top teaching hospital and expect to wait weeks at the most.
So can I. I've never had to wait more than a couple of weeks at most. If it's urgent, they fit you in on the same day or a couple of days later at the latest. That seems to be corroborated by [1]. One exception is mental health care, where the waiting lists are long.
> There is no way to offer that level of service to anyone and not explode costs, let alone contain them.
That is wrong. According to [2], health spending accounted for 10.9% of GDP in Belgium in 2012, which is much lower than the 16.9% the US spends.
[1] http://focusonbelgium.be/en/international/belgium-has-shorte...
[2] http://webcache.googleusercontent.com/search?q=cache:2VeNWmB...
Anyway, it's not clear to me that Belgium has anything like a single-payer system[1]:
The Belgian population enjoys good health and increasing life expectancy of 79.5 years (2004). Most Belgians have access to health care of high quality, financed mainly through social security contributions and taxation. Compulsory health insurance is combined with a mostly private system of health care delivery, based on independent medical practice, free choice of physician and predominantly fee-for-service payment.
That doesn't sound at all like single-payer.
[1] http://www.euro.who.int/__data/assets/pdf_file/0007/96442/E9...
That's exactly the point! Single-payer is much better at containing the costs. The cost of a GP's visit is fixed centrally. And somehow we still end up with more doctors per 1000 inhabitants than the US.
> Belgium is also over 10x as population dense as the U.S., which offers significant opportunities for more efficient care delivery.
States like New Jersey and Rhode Island have higher population densities than Belgium. Is health care significantly cheaper there? A cursory glance at [3] suggests otherwise.
One big difference between Belgium and the US is that damages in malpractice suits are not determined by jury, and hence much lower.
> Anyway, it's not clear to me that Belgium has anything like a single-payer system[1]:
What is your definition of single-payer healthcare? If I look at wikipedia [1]: Single-payer healthcare is a healthcare system in which the state, financed by taxes, covers basic healthcare costs for all residents regardless of income, occupation, or health status.
The Belgian health-care system covers everybody, financed by social security contributions and taxation. The compulsory health insurance is about 75 EUR per year, and amounts to simply another disguised tax. What is not single-payer about that?
There are deductibles for doctor's visits (e.g. 6 EUR for a GP visit), but your total healthcare costs are capped at 459 EUR per year (even lower for low-income families). Anything over that is covered by social security.
You can get optional, extra health-insurance which can cover additional services. E.g. if you prefer a single room when you are hospitalised, that costs extra. Some extra health-insurance covers nonsense like homeopathy, which is otherwise not covered.
Btw, dental care is included in basic coverage. No third-world country situations like [2].
[1] https://en.wikipedia.org/wiki/Single-payer_healthcare
[2] http://www.washingtonpost.com/sf/national/2017/05/13/the-pai...
[3] http://www.kff.org/other/state-indicator/health-spending-per...
In any event, you'd still be asking millions of Americans to switch health care plans when they're satisfied with what they already have.
BUPA et al primarily provide slightly nicer rooms for inpatients, might be more flexible on times you can see a doctor, might provide more personalised information on general health stuff (e.g. "how do I lose weight/get fit?"), and might allow you to see a doctor slightly sooner for stuff that's not going to kill you.
I do not believe that Americans as a whole are satisfied with what they have. I believe that you are, since you have significant income and can get coverage for anything you like. I talk to people on a daily basis who have to worry about what treatments they are able to afford for their diagnosed disorders. For many of them, surgery is required for which they have to save up for a number of years and then visit another country, while paying extortionate (in relation to their income) prices for life-saving medication all the while.
And of course, there's like a 50-50 chance that Ms. Smucker is actually out of network by the time you see her, and you'll get a $2,000 bill to pay.
Take out the profit motive and you can build systems to actually make people healthier: networks of clinics and registered nurses and family physicians to handle the bulk of the work (which is, after all, mostly routine) backed up by specialists for the hard cases, and everyone with a mandate to do what is best for the patient rather than what makes the most money. That's what other countries do and it works extremely well, providing better health outcomes than the USA for a fraction of the cost.
Currently, their insurers are not heavily restricting them, because they're paying for the privilege.
But honestly I think single payer is just part of the solution. You also need public hospitals, because hospitals have no incentive to suggest a good but cheap solution to a medical problem.
I read a book, where an American went all around the world with the same ailment, got examined and suggestions for procedure to treat it. A VERY telling outcome was that in the US only the most expensive and complicated procedure was suggested to the patient. In other countries he was informed about cheaper and far less invasive procedures. Which btw worked and made him happy, so he avoided a complicated and potentially risky surgical procedure.
This is a problem with the US system. There are something like 2-3x as many surgical procedures that needed often simply worsening the well being of the patient. This is the flawed American thinking that good health care is the same as getting lots of complicated medical procedures.
The drug consumption is also astonishing. When using American health care I was shocked by how aggressively they pushed medication on me. People are trying to push medication on people everywhere in the US. Doctors, commercials, drug stores etc. You are not a patient. You are just a customer.
The US system really just leads to the health care sector focusing on pushing as many expensive drugs and procedures on the people who can pay for them an ignoring the rest, regardless of whether that brings better health or not.
* Import more doctors from other countries with a streamlined visa process
* Provide free training to doctors for underserved specialties
This is not hard. It is supply and demand. If demand increases, you find ways to increase supply in a cost-efficient manner.
I don't get why voters think there is something inherently worse with paying taxes than paying insurance companies.
Taxes have the benefit that they can not typically be higher than your income, while insurance can easily be higher than your income.
If you are sick for a long time with say cancer treatment and lose your job, then your insurance costs will quickly get higher than your income.
Perhaps if legislators actually knew how to legislate this would have stood a chance at passing.
Nowhere close. It would have doubled the budget at an additional $200 billion dollars, and this is for a state in which 70% of healthcare expenses are already paid for by public funds.
If you can save $10 by paying $5, and your argument for why you won't do it is that it costs too much, I'm going to tell you that you need a math course.
What it seems to actually boil down to is bribery.
It's not simple math though, it's politics and projections from people with an agenda. If you tell me I can save $10 by paying $5, it's my responsibility to decide if you're lying to me, to question your assumptions, etc. Maybe it costs $8 to save $10, but I give up significant other rights/options/etc.
TLDR, it's not just math, and the math isn't that simple.
But you won't be saving money. Think of it as a conservation of matter problem in physics.
The current insurance model covers some set of care for some subset of people. The goal is to provide more comprehensive care for more people - i.e., much more care will be provided in total. The supporters of government-provided healthcare (whether it's this CA bill, or ACA) don't want to look at this bigger picture and acknowledge that they really are proposing to spend a lot more.
Not only will this cost more, but pushing more care through the existing infrastructure will also result in long waits for care and the other kinds of things people in Canada and the UK complain about. If the infrastructure was built with a given amount of usage, vastly increasing that usage will overtax the infrastructure. And with the financial concerns that surround the problem, it's quite a stretch to say that the capacity will be increased.
Your implication is that because they're the only buyer, sellers will be forced to fall into line. That's not applicable in this situation, for the very same reasons that the bill's proponents claim that a free market system doesn't work.
For the negotiation that you're implying to work, it has to involve the possibility that the potential buyer could say "no" and walk away. In this case, it's not going to happen. There's just no way the government can say no to, e.g., a revolutionary treatment for AIDS - the political constituencies simply won't let it happen.
So what we'll be left with is:
- Treatments for maladies involving well-organized constituencies will get disproportionately better coverage. So AIDS or breast cancer will have much better care than, say, colon cancer.
- The choices in these negotiations will be made by those hyperbolic "death panels". Yes, the GOP were exaggerating a lot, but when it comes down to it, somebody has to decide where finite resources will be spent. Somebody in the government is going to be deciding if your affliction is the one that gets left on the negotiating table in order to close the deal.
I wish I had $1 for every time someone told me I was "guaranteed" to save $10 later by paying $5 today.
Now, instead of an alleged guarantee, let's change that to "we admit we don't even have a concrete budget estimate that demonstrates how this will save money, but take our word for it that at some point it'll pay off. And in the mean time, we need to triple the state annual budget". That's a much harder sell, especially at this scale, and especially when the majority of people are actually satisfied with their personal insurance situation as it is.
Another nail in the coffin is that of the many proposals to shift tax deductions away from the rich is to remove the Federal deduction for State and local taxes. High tax states need this deduction to hide their spending. It reduces by a lot the amount of Federal taxes paid in those states to benefit local coffers. Without the deduction tax increases become a real threat by increasing the chance those with large taxable incomes move
Citation required.
Also are you talking about the marginal rate or effective rate?
Certainly much of our spending is inefficient or flatly wasteful, but it would be very difficult to slice it by 20 or 40% at the stroke of a pen. Those hospitals have been built and require maintenance. Those doctors and nurses went heavily into debt for their educations, and so on.
People mention better access to specialists in a privatized system... I'd argue the peace of mind of not having to worry about healthcare costs far outweigh whatever advantages a privatized system may have.
Anyway a problem with a public option for the few is that there will be no political pressure to make it good. You see this in every country which offer public and private options, where the rich primarily chose private. The public option turns into crap because the very people who could have put heavy political pressure on the public option don't care.
This is the experience we've had in Norway at least through history. If you want good public services, they need to be universal and apply to both rich and poor people. Means tested solutions only for the poor or disadvantaged always end up crappy. When somebody is universal, everybody gets a stake in it and a desire for it to be good, including the politicians who get elected.
If all the politicians and the bankers on wall street had to use VA, you can bet it would have offered great service.
Once great example of this dynamic is from the 60s when they forced mixed schools in the US. "black schools" which suddenly got white students, suddenly got all sorts of maintenance work taken care of. Those schools got big upgrades due to that. In short if people with power and influence has to use a system, it will get a lot better.
just be honest about it.
I would probably have used VAT for this.
The well has been poisoned, so discussion will be heated and no actual policy can be discussed.
https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
The US spends more on socialized medicine than countries like Japan and Great Britain spend in total.
It is a very bad situation here in the US.
The budget estimates indicate that it would be about 50% more expensive than the status quo, after accounting for private expenditures.
Amazing they needed a whole article to say this. How disjointed from reality do people have to be to go through the legislative process with something that fiscally infeasible?
We're seeing it happen again in Congress with the ACA replacement.