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Comment by JonFish85 | Hacker News Reader

In a word, the answer is still "cost". You can try to dance around it and talk about how " A single-payer program would inevitably incur additional taxes, but the overall health care costs would be lower for most people and businesses", but at the end of the day, it's going to cost a lot of money. This article claims it'd "only" cost about an additional $100b or so in CA; I think critics would be very skeptical of that, especially since costs are claimed to come from "reduced overhead" areas. I'm not sure that governments have a history of keeping costs low, so voters would likely be skeptical of that.

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.

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> I'm not sure that governments have a history of keeping costs low, so voters would likely be skeptical of that.

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.

Private insurance and delivery of healthcare is the crux of the cost problem.

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.

Agree cost is a huge factor, but another key issues is the inconvenient fact that most Americans with employer-provided coverage are satisfied with it. Convincing them to take a leap into the dark with no credible promises that they could still see the same PCPs and specialists they can see today and with similar wait time/referral requirements would be politically Herculean.

> they could still see the same PCPs and specialists they can see today

What do you think single-payer is? There's no such thing as "out of network".

I don't think single-payer works the way you seem to think it does in nations where it's been implemented.

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.

Do you have anything to backup that claim?

Is that whole "supply and demand" thing not convincing enough?

> There is no way to offer that level of service to anyone and not explode costs, let alone contain them.

* 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.

The French system is similar to that. You're right it's more expensive in terms of government expenditure than the US, although quite a lot cheaper in terms of combined public-private cost.

Is the French system true single-payer? I thought it was a hybrid system that allowed for significant private supplement.

I think it's a single payer system with an additional premium coverage, which can be covered either by copayment in the event, or with private insurance.

The UK has a dual model - NHS for everybody, and if you have spare money, you can additionally pay for additional services through insurance providers such as BUPA or paying directly. BUPA et al have reduced costs due to not having to cover a range of conditions, not having to indirectly fund A&E departments, being able to deny people coverage for preexisting conditions, etc etc. It's very unlikely that the US would ever deny people the ability to pay for healthcare if they chose to.

Then we should stop using the term "single-payer", which describes a system like Canada's, where private payments to providers are illegal.

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.

We do have single-payer healthcare for all NHS services. You cannot pay for NHS services, and NHS services will cover almost everything you'll ever need so long as the treatment is actually proven to work - it's a newspaper-worthy situation when the NHS denies treatment, and usually that only comes into play with e.g. very new cancer treatments. Every citizen of the UK can use NHS services as a right, whether they pay taxes or not. If you have an emergency, you will be taken to an NHS A&E department.

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.

"You cannot pay for NHS services" is almost a tautology, since whether a service is NHS or not is defined by who pays. You certainly used to be able to pay for services carried out in NHS facilities using NHS equipment, generally outside the hours the NHS was willing to pay to run them. You can pay to see people privately who also work for the NHS too.

But of course that "service" is mostly waste. If you self-refer yourself to Dr. Smucker, the best [foo] surgeon in the business, you're likely to find that your [foo] isn't broken at all and even if it was, it doesn't need surgery. So you've wasted Ms. Smucker's time and your insurance company's money, and you haven't made anyone, including yourself, any healthier.

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.

We can argue about the potential cost savings of restricting who patients can see and when, but that's my point! Politically, telling folks who are happily "wasting" money on medicine that the government and not their doctors will decide what they can and can't have is a huge loser.

Currently, their insurers are not heavily restricting them, because they're paying for the privilege.

Insurance companies are not different than government, they also try to limit your usage of health services. Every time you get service it is an expense for them.

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.

I think the book you are referencing is The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care by T.R. Reid.

> I don't think single-payer works the way you seem to think it does in nations where it's been implemented.

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...

The Belgian system contains costs in other ways. For example, doctors (especially GP's) are paid significantly less. Belgium is also over 10x as population dense as the U.S., which offers significant opportunities for more efficient care delivery.

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...

> The Belgian system contains costs in other ways. For example, doctors (especially GP's) are paid significantly less.

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...

I can only compare to Norway, which is not single payer but socialized kind of like NHS.

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.

As someone who likes their employer healthcare, I would like to be able to seek other work or build my own business without having to worry about getting injured.

Why should voters care if they pay the government for a service instead of private enterprise, if government can provide the service for a lower price?

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.

No, it really isn't. It was just botched legislation. The "bill" was totally unfeasible without more details and a plan for how to pay for it. It's not like it's inherently unaffordable or that the cost is too high. The estimates in the article are pretty much in line with what California already spends on healthcare.

Perhaps if legislators actually knew how to legislate this would have stood a chance at passing.

> The estimates in the article are pretty much in line with what California already spends on healthcare.

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.

But the net cost to voters is highly negative, and voter support is very high.

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.

"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."

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.

> If you can save $10 by paying $5

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.

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.

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.

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

The U.S. military has essentially a monopsony on high-tech weapons systems like the F-35, but somehow it doesn't see great efficiencies in pricing.

Pasting a link with no words is a cheap reply. If you can't spend the time to actually formulate an argument, it's hardly worth the time to reply to you.

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.

Sure, but what literally killed it is a constitutional provision that non revenue neutral laws need to be introduced by a popular vote.

Even Vermont; Green Mountain Care; ran away from the idea simply because they could not find the stomach to pay for it. It was supposed to start in 2017 when the ACA permitted such arrangements. to even get close to a palatable number they would force cuts in payments to doctors, hospitals, and more, by nearly twenty percent while doing nothing to reduce the operational costs of such providers.

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

The rest of the developed world affords it by paying up to 60% in taxes, like where I live, and still seeing private doctors if you don't want to wait months.

Also much lower salaries for doctors and nurses, as well as building hospitals that are more like public schools and less like luxury hotels.

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.

> paying up to 60% in taxes, like where I live

Citation required.

Also are you talking about the marginal rate or effective rate?

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