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Realistically, if the employer doesn't have to pay out for healthcare, won't they have funds available to give the employee a higher salary to make up the differences in taxes? Ideally I'd like to see universal healthcare taxed similar to current FICA -- employee pays a share, and the employer pays a share. But since the employer typically covers about 80% of premiums now, it would make sense for them to do the same with the higher taxes.

The employer shouldn’t “pay” anything for FICA. They should increase salaries by the FICA amount and the entire amount should be deducted.

It would be a wake up call to see how much we are really paying in taxes.

> It is pure fantasy to assume we can get universal healthcare without European level taxes

Agreed, but is anyone really arguing this? The US has very low overall taxation rates (as a % of GDP), well below the OECD average. It should come as no shock to anyone that in order to get Euro-level services, we need a higher tax burden. High earners have the most to lose so it's also not a huge surprise it's an especially concerning issue for them. Most Americans (including those that would benefit most from these changes) are not high earners and they will pay a more measured amount.

I'm not an expert in health care cost containment but there are many doctors, administrators, and number crunchers in the industry who think we can get there if we want it badly enough. Over one third of our total health care expenditure is on administration. By some estimates, we'd drop 15% of the cost (in the trillions) overnight with a single payer system. It's a good start.

No you don't pay less in tax. Sweden does it with 7% of total tax being cost of healthcare. Poland scrapes by with 5% PKB being 26 billion USD. US pays more than 10% from tax and much more on top privately. Your taxes are not that much smaller to account for the difference, while the country is bigger.

Yes, a single payer would have huge negotiating power to drop these silly costs you pay.

> It should come as no shock to anyone that in order to get Euro-level services, we need a higher tax burden.

This isn’t really true with healthcare. We spend 2-3x what Europeans do on healthcare per capita. We even spend about the same in taxes as they do, PLUS our immense private spending.

https://www.kff.org/health-costs/issue-brief/snapshots-healt...

We also spend more to get less than Europeans on many other dimensions. There is no reason to believe that we'll be able to cut costs to European levels when we can't do anything else for European levels of spending either. (For the same price as Maryland is spending to build a suburban light rail, Denmark is building a fully automated subway line underneath downtown Copenhagen with more track miles. The notion that just making the public sector handle healthcare will bring costs down to European levels is utter fantasy.)

At the very least, I think you have to assume we won't be more efficient than Europe in terms of getting healthcare spending down to a lower percentage of GDP. If we get healthcare spending down to 11.3% of GDP like France, we still have to find about $2 trillion per year in taxes to cover that cost.

> If we get healthcare spending down to 11.3% of GDP like France, we still have to find about $2 trillion per year in taxes to cover that cost.

Are you asserting $2T in taxes is somehow worse than the current $3.5T we pay for healthcare (taxes, premiums, out-of-pocket)?

> At the very least, I think you have to assume we won't be more efficient than Europe in terms of getting healthcare spending down to a lower percentage of GDP.

At the same share of GDP, we’d still be vastly less efficient per capita.

> If we get healthcare spending down to 11.3% of GDP like France, we still have to find about $2 trillion per year in taxes to cover that cost.

No, you only have to find a bit under $0.8T, because public healthcare spending is already a little over $1.23T of the $2T it would be under that model. And I think people would be happy to lose ~$2.3T in private bills for ~$0.8 in additional taxes.

> Agreed, but is anyone really arguing this?

Everyone is arguing this. None of the Democratic candidates who have proposed Medicare for All have proposed corresponding European-style taxes. Nobody has proposed a VAT, which averages 20% in the OECD. Sanders has given a "menu" of options, none of which raise anything close to the required revenue. The closest thing in Sanders' plan is a 4% employee + 7% employer payroll tax. That's less than what Germany or France assess in payroll taxes to fund their healthcare systems. All of Sanders' proposals put together only raise about $13 trillion of the projected $30 trillion over the next 10 years: https://www.sanders.senate.gov/download/options-to-finance-m....

> It should come as no shock to anyone that in order to get Euro-level services, we need a higher tax burden. High earners have the most to lose so it's also not a huge surprise it's an especially concerning issue for them. Most Americans (including those that would benefit most from these changes) are not high earners and they will pay a more measured amount.

Actually, middle income earners "have the most to lose." Again, look at how Europeans actually pay for their universal healthcare. Here in Maryland, the top marginal income tax rate is 42.75%, as compared to France or Germany's 45% rate. The top marginal rate in New York or California is higher than in France or Germany. What pays for the healthcare is not higher taxes on "high earners" but higher taxes on middle income people. In France, the 41% tax bracket kicks in at $83,000. In Maryland, the marginal rate on that income is just 26.75%. (In Texas, it's just the 22% federal rate.) Capital gains is higher in France, which is unusual among even European countries in taxing capital gains like ordinary income, but there's not much capital gains income to tax. ($650 billion or so in the U.S.). Germany's and Sweden's capital gains rate is 30%, about the same as Maryland. Corporate taxes in both France and Germany are comparable to or lower than the U.S. (after Trump's tax cut).

To fund universal healthcare, we need to raise another $3 trillion per year in taxes. The total income of the top 1% is 2 trillion. Raising taxes on those people to French or German levels won't raise much more money. This is obvious from Sanders' proposal: https://www.sanders.senate.gov/download/options-to-finance-m...

Sanders proposes to raise the top bracket to 52%, above France's or Germany's. It proposes to treat capital gains as ordinary income, like France but unlike Germany, Sweden, etc. Even raising taxes on the rich to levels higher than France only raises $1.8 trillion over 10 years. The payroll tax proposal, by contrast, raises $7.7 trillion, four times as much. Going all the way and raising social insurance taxes to French levels would raise 5-6 times as much as raising taxes on the French to higher-than-France levels. So would a European style 20-25% VAT.

How other countries finance their health care is incredibly wide-ranging. The point is that revenue-raising tax policies are being included in proposals to close the gap, not that they mirror how Germany and France do it exactly. Some candidates have not put forth detailed tax plans but nobody is saying we won't have to significantly raise revenues to pay for it.

> projected $30 trillion over the next 10 years

This is a projection and there is much disagreement. If we spent as much per capita as Canada, the cost would go down by around 50%. Single payer is not feasible at the cost per person the US currently spends. Every other country in the world spends less (a LOT less). We have a lot of real examples to follow.

> Actually, middle income earners "have the most to lose."

You have a good point, here, but again it could vary significantly depending on revenue-raising changes that are enacted. The Sanders plan includes mostly progressive tax changes.

> but nobody is saying we won't have to significantly raise revenues to pay for it.

Actually I dislike this statement - the federal government will be collecting and disseminating a lot more money than it is today, but less money will come out of people's pockets. It is the case that taxes will go up, but "taxes + health insurance" today is more than "tax + health insurance" under medicare for all, the tax goes up, the health insurance becomes 0[1].

1. At least for primary care, it's highly probable that a lot of "extra" medical care wouldn't be captured like vision insurance, dental and pharma.

"Our neighbors, who have solidly middle class jobs but good health insurance benefits, will end up paying more in taxes than they will save in out of pocket health expenses."

This will be influenced a lot by whether the employers give what they currently pay to provide healthcare back to the employees or if they just pocket the difference.

> The CBO estimates it will cost $3 trillion a year to provide universal healthcare.

That’s not $3T on top of what we currently spend, though. It just moves payments that go to insurers over into taxes. We already spend that $3T (and more!) on health care.

We know from the rest of the developed world that this is cheaper, too.

The single payer could force it to be cheaper. Much cheaper. In Poland we scrape by with 5% PKB which is 26 billion USD. But there's not enough doctors and nurses.

PKB=GDP (in case anyone is confused).

Our neighbors, who have solidly middle class jobs but good health insurance benefits, will end up paying more in taxes than they will save in out of pocket health expenses.

Someone is paying for insurance - that’s just a part of your compensation that is deducted from your paycheck. Theoretically, that means employers should pay you more. I think it would help the cause of universal health care if employers were not allowed to subsidize health insurance invisibly. They should increase everyone’s paycheck by the amount they are subsidizing the insurance and then have it as a line item deduction.

Yup, this is one of the biggest problems with American healthcare - a lot of people don't actually know how much it costs, because that cost is hidden in their employee benefits.

When Obamacare came around, I saw people complaining it'd cost them $1k, and comparing it to the $40/month they had to chip in on their employer plan, as if that was the total cost of it.

> The CBO estimates it will cost $3 trillion a year to provide universal healthcare.

You forget about the fact that universal healthcare will bring healthcare costs down as fuck. Ever looked at the price of a GP appointment before insurance in France and the US ?

It won’t. The US is structurally incapable of offering public services efficiently: https://www.nytimes.com/2017/12/28/nyregion/new-york-subway-...

> And The Times observed construction on site in Paris, which is building a project similar to the Second Avenue subway at one-sixth the cost.

This is an extreme example, but this is the persistent story of government programs in the US: they do far less while costing far more than in European countries. The US spends almost 30% more per student on K-12 education while getting worse results.

Why is this? Massive corruption? Regulation? I'm not disagreeing with your assessment at all.

Unions, organized crime, greedy capitalists, environmental and worker safety regulations, and/or Baumol's cost disease, depending on who's answering the question

Europe has all of these, and their unions and regulations are substantially stronger even.

I was thinking, it might be the cultural tendency to make really long work weeks / hours, but spend a lot of those hours slacking off (see also the thread about the boss-detector arduino thingy). As if they're paid for time, not work.

You linked to an article that takes care to mention that it is specific to New York and presented it as indicative of the entire US. That piece links to a blog post describing cost-per-mile of US rail in general [1]. That post demonstrates that NY is a huge outlier, with only London in a similar league. Our Central Subway here in San Francisco, as much of a mess as it is, has been nearly an order of magnitude cheaper per kilometer to build than the East Side Access in New York has.

The problem of excessive cost for rail, for the most part, is specific to English-speaking countries and Japan, not just the US. Quote: "Observe from the low costs of Italian subways that corruption alone cannot explain high American and British costs. High Japanese costs can be explained by strong property rights protections and a process that favors NIMBYism…"

There was a study that I can't find offhand that led to really interesting conclusions: despite the tendency of everyone to think that their own locale's government is uniquely inefficient, wildly late and over-budget public works projects are the norm everywhere. (Look at the Amsterdam North-South line in that blog post, now 2x over budget, for example.) Public support for most infrastructure megaprojects wouldn't be nearly as high if authorities were better at estimating costs. But that means that, if authorities were better at calculating costs in advance, virtually nothing would be built, including things that everyone now considers essential such as the Interstate Highway System (estimated at $25B over 10 years, actual $114B over 35 years [2]). The tendency of public works projects to be delayed and over-budget seems to be, paradoxically, what allows us to make progress in the first place.

[1]: https://pedestrianobservations.com/2011/05/16/us-rail-constr...

[2]: https://en.wikipedia.org/wiki/Interstate_Highway_System