California Considers Doubling Its Taxes
taxfoundation.org
taxfoundation.org
This is key here. So instead of paying this out to a private insurance company I pay it in taxes, there by my actual change is net zero, in most cases. I have a feeling most reactions might be headline driven here.
I think it’s worth doing the math on how much it costs you in healthcare coverage before really judging a book by its cover here. If my compound deductions are the same who cares if it’s just taxes?
In addition, your employer now has to pay more based on their gross receipts and if you make more than 150k a year you are paying even more.
We have good plans too but still have our deductibles which, if I remember right, are around $1,000.
I mean - plans my work offers (which aren’t even the best) are like $500/month out of pocket for the entire family - and that’s for really good coverage with no deductibles and low copays. The plans they offer aren’t even the best I’ve gotten…
It's a little trickier to account for when the employer is 'self-insured' for healthcare. They'll use an insurance company to administer benefits (and pay for that), but they'll pay the costs for treatment rather than paying into an insurance pool and having the pool pay the costs.
The distinction is subtle, but in my mind having it structured as an individual paid income tax would yield better results for edge cases and not incentivize bad corporate behavior like running 1099 contractors instead of FTEs.
https://www.irs.gov/affordable-care-act/form-w-2-reporting-o...
Grandfathered plans are an absolutely screaming deal. You can do an HSA plan with a $2000 deductible and low OOP max, fully fund the HSA ($7,200) and come out way ahead at modest cost. This let's you do things like vision / dental / chiro / accu / whatever day to day stuff on the HSA, then keep costs controlled (after 2K) for a major issue. If you don't end up using the HSA you can basically use it in retirement.
The obamacare bronze HSA plans (which actually cost a bit more) have a $4,800 ind deductible and something like a $13K (!!) out of pocket max and something like a $9K+ family deductible limit. And they cost more. This is totally unworkable absent the subsidies.
I like obamacare, but something happened as part of obamacare that has CLEARLY driven up costs. Is it the lack of limits (ie, $10M in coverage during last weeks of life?) Is it some sort of other mandate?
One area where govt care is better priced is for the elderly. The grandfathered / free market type plans get expensive at 60 years +. The obamacare plans are more of deal here (relatively). At the 20 year old range obamacare is horrible for the coverage if you actually have to pay for them.
It would be kind of similar to forcing auto insurance carriers to afford coverage to cars they didn’t previously insure after they had already been in an accident.
Bigger than denial was recission, where if you ended up with an expensive to cover condition, your insurer would fine-tooth-comb your history for evidence that you had a preexisting condition that has not been revealed, cancel your coverage, and leave you uninsured and uninsurable; recission for reasons other than proven intentional fraud was prohibited by the ACA, which is a pretty big deal.
Since the insurance companies now have to cover pre-existing conditions, and don't want to do that, they came up with another plan: don't answer the phones except during open enrollment. I tried calling several insurance companies (major carriers) just to get quotes for health insurance, and none returned my call. Some had phone trees that went in a circle so you could not get to a person. I did get one broker to talk to me, and he said pre-existing conditions weren't covered for 24 months. First, that's a lie, and 2nd, it's illegal (ACA outlawed this practice).
By only accepting applications during open enrollment, the insurance companies have effectively done an end-run around the law against pre-existing conditions.
Note: this is for an individual to get insurance. I'm sure companies can get insurance for their employees any time they want it.
Follow-up: it turns out that if I did have PPO insurance and was covered at Mayo, then with the same bill from Mayo it would have cost me $8000 more with coverage than it did without insurance, paying cash. That's truly f'd up!
And the requirement that 80% of premiums paid had to go to paying for care was supposed to prevent insurance companies from jacking up prices to increase profits.
Neither actually made an attempt at fixing the underlying problem of health care being expensive.
That's an easy one, Obamacare mandated that insurance companies couldn't charge more than X times as much for their most expensive plans vs. their cheapest plans, The people pushing it were either tremendously ignorant or outright lying and claimed that this would make plans cheaper, while critics rightly predicted that instead of making the most expensive plans cheaper they would make their cheapest plans more expensive.
[1] https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-In...
I'm pretty sure I do know the answer to that question...
Well, if they didn't, you could just change jobs. The old benefit of working for an employer that paid all of your premium would be gone, so that wouldn't be a reason to stick with them.
I suspect a GRT is also a regressive form of taxation (just as sales taxes are, though many [most?] states exempt food and other staples from their sales taxes, to minimize the regressive nature of these).
As a libertarian, false dichotomies between de jure and de facto government are really bothersome. There are certainly arguments to be debated about single payer. There are certainly arguments to be debated about this particular attempt at "single payer". There are certainly arguments to be debated about who may be shouldering more or less of the costs with this plan. None of them are discussed here.
How is the high speed train project coming along?
So your comment only covers less than 10.5% of people at the moment... a little more than the number of people who have no health coverage (a good portion not out of real choice).
And that does not even cover how horribly this sort of market functions: you never know how good or bad your coverage actually is until you go to use it for a particular problem, and then you don't really know that until it is over and you are maybe bankrupt. Health insurance is the worst place to try and use market forces to regulate it... well maybe after military, fire, and police...
You can't, because the health insurance is provided by your employes so you get whatever they give you.
My health insurance (blue shield) is absolutely terrible (right now I need some medicine they refuse to let me have because it cuts into their profit margins) but there's nothing I can do about it.
And that's after paying $2500/month for the privilege.
I guess I should be thankful my insurance is ~$1000/mo, and hasn't left me with the horror stories some seem to experience.
That's not true, is it? You could decline coverage and then go purchase a policy of your own elsewhere. Yes, that might be expensive but the original claim was "Y'all actually have one of the best systems in the world, it's just way too expensive." and that still tracks.
Even better, you could purchase a policy through the Obamacare exchanges.
If the government offers you bad medical care, you turn to the black market or you fly to the US to get the procedure done because the government has banned alternative care. This is a very normal Conservative talking point and the inherent competition in US healthcare is arguably the biggest benefit of its current system.
What other choices exist, there's only a few giant insurers anyway.
> Even better, you could purchase a policy through the Obamacare exchanges.
I have no direct experience, would love to be wrong, but what I've heard is that even the top-tier plans are extremely limited in what they cover and where they are accepted so it's even worse than company-provided plans.
Basically, get in contact with them, try and get an override, or get them to explain why you are not covered. If it isn't in the formulary your employer opted into, you're hosed; but there is usually one way or another to get them to give in, they will just make you go through maximum hoops.
Ask for their clinical people if you can't get any traction. They will likely be the ones with hand on the knob for whether a drug is "worthy of coverage" or not.
Magic words: Override,coverage decision appeal, utilization management/formulary question.
They will tell you to check a website. Look up your thing in their formulary, if not there, abort. If in there, but high-tier, prepare for the prior-auth gauntlet.
I gave up on BCBS and have resigned to paying out of pocket, but you might get luckier than me. They will generally fight tooth and nail to be difficult, but just keep a cool head and keep escalating. It's been a while since my last butting of heads but I'm gearing up for round 2.
Also remember: You can pay out of pocket, but you'll be at the whims of that pharmacy. They'll generally help you work through coupons.
> Also remember: You can pay out of pocket, but you'll be at the whims of that pharmacy. They'll generally help you work through coupons.
I did ask, but it was nearly $1K/week so can't afford that.
You have now reached beyond my "letters/phone calls to Congress" threshold. Generally doesn't get an instant response, a d may take months, but surprisingly does occasionally get some traction. More out of spite than anything else. However, there is increasing regulatory attention being directed at the space, and even some states have insurance regulators you might be able to hit up.
It's unfortunate, but there are some drugs that insurers are simply not willing to be on the hook for, and if you're the unlucky person suffering from a rare, expensive to treat condition; the only way around it is to make a lot of noise and waves, and be open to trying alternative regimens.
No one should have to go through that though. Good luck.
The net effect is predictable - Canada consistently ranks very poorly in international health system comparisons. We have far fewer ICU beds, doctors, imaging machines, etc. per capita than peer nations, and the entire country is in varying degrees of harsh lockdown because our hospitals were already overwhelmed during a normal flu season.
What states should do is encourage more competition as a way to lower healthcare costs. Y'all actually have one of the best systems in the world, it's just way too expensive.
Germany has more ICU beds than the US.
That would be shocking if true, which it does not appear to be.
Germany has around 32K ICU beds. US has around 96K ICU beds.
Germany has slightly more per-capita than the US. (387 vs 294 per million inhabitants)
https://en.wikipedia.org/wiki/List_of_countries_by_hospital_...
Not sure what the original poster is talking about, but America's healthcare system is fucked. And it's not just fucked because it's expensive.
I would love to see an international ranking that places Canada's system below that US that isn’t just coming out of some right wing think tank.
Funny that despite this 'extreme example', Canadians have almost 3 years longer life expectancy than us in the US, are healthier throughout their lives, and have comparable or better outcomes with treatments. Where the US has better outcomes (e.g. - some forms of cancer, some organ transplants), it's only very marginally better (like 1% higher chance of surviving 5 years after colon cancer diagnosis when compared to Canada). And for that 1%, you're spending MUCH more money on your treatment.
Basically nearly every measured outcome is better in Canada rather than the US, despite US paying twice as much on healthcare costs per capita when compared to Canada.
> We have far fewer ICU beds, doctors, imaging machines, etc. per capita than peer nations, and the entire country is in varying degrees of harsh lockdown because our hospitals were already overwhelmed during a normal flu season.
That may all be true, yet it's still better care than what the average US citizen gets, despite paying twice as much per capita.
> What states should do is encourage more competition as a way to lower healthcare costs.
They've been trying to 'encourage more competition' for decades now with healthcare costs only continuing to climb while affordable access falls (ignoring the gains that came and went with ACA). "Competition" doesn't exist in industries that are nearly impossible to enter due to regulatory capture and the insane entrenchment of giant healthcare organizations. The few that succeed in making any progress at all get rapidly acquired.
Reality is that no-system is perfect, there will be complaints and tradeoffs. But the US system is broken for a huge proportion of residents, and it's not going to change without drastic measures. I'm all for torching the whole thing and trying single payer. There may be complains about single payer systems across the world, but according to most of the publications I've seen (probably all, but my memory is imperfect), the vast majority of those subject to it would never trade it for what the US has.
Basic healthcare access in 'the richest country in the world' should be a fundamental right, not a for-profit industry.
Which is more likely caused by different lifestyle choices (e.g. 27% vs 42% obesity rate). Also if you take out all the southern states the gap get quite a bit smaller (e.g. 82.4 in Ontario vs 81.7 in California and 81.4 in New York).
As for "fundamental right", this is not really how rights work and it's dangerous to define them that way. You have the right to bodily autonomy, freedom of speech, etc., but you don't have the right to someone else's labour. Rights are generally protection against interference from others, not an obligation to receive something.
Broad access to healthcare across socioeconomic status is a worthy policy goal, but saying it's a "fundamental right" begs the question: how much healthcare are you entitled to, exactly?
There's no free market for health insurance for the people who need care. Insurers don't want those people as customers, not from any state. They're money losers.
What pressure is there to lower costs? Why would they charge less?
Really? From what I can find on the internet, CA state income taxes are usually in the 10% range for most folks. Are you really paying 10% of your income for health insurance? I'm paying about 2.5% right now.
I highly doubt that number is only 2.5%.
The COBRA monthly pricetag is $2093.
While employed (at this Fortune 300 company's San Jose, CA office), I was paying $425 per month out of pocket for the same set of plans.
[1] https://www.bls.gov/ncs/ebs/factsheet/medical-care-premiums-...
The 9.3% marginal bracket stretches from 61k-313k. (260k is the 95%ile for CA tax returns, so minor-increase brackets above this one don't matter all that much) 10.3% is 313k-375k. 11.3% is 375k-625k. (99%ile is 680k)
At 61k, at the end of the 8% bracket, the real tax rate is still just 4.40%. At 100k, 6.30% actual. At 150k, 7.30% actual. At 313k, 8.32% actual. At 375k, 8.67% actual. At 625k, still only 9.72% actual tax rate. We finally cross 10% actual at about $702k AGI.
It's really, really important to keep in mind how much marginal rates mess with calculations, particularly when estimating.
Also, Californians are statistically much poorer than people often expect, especially around here.
[1]: https://www.nerdwallet.com/article/taxes/california-state-ta... [2]: https://www.irs.gov/statistics/soi-tax-stats-adjusted-gross-...
(I pay out of pocket via a side business, not from my current employer.)
Maybe it would be a good idea to lean on the better insurance companies (are there more than kaiser?) to administer.
Personally I think there needs to be stronger regulation so that they can still make some profit (not obscene) for incentive to get more efficient, while regulating they can't take that profit at the expense of patients & access to care.
All that money is overhead that can be removed from the costs if health care didn't have to funnel through a private company taking profits from it.
https://www.fiercehealthcare.com/hospitals/kaiser-permanente...
Certainly not the salaries to actual health professionals (doctors, nurses, techs, etc).
When you see a doctor for 10 minutes and get billed $400, the vast majority of that money goes all the layers who are extracting their slice of profit from it, only a small bit goes to the doctor.
The us has the most expensive drug approval process in the world making any drug that goes to market needing high prices to exist. Around 10% of NH spending here.SP does not fix this.
Hospitals receive large gov funding, regulatory protection that includes the inability to build or run new or for-profit hospitals, and with the constant moral hazard of running hospitals in the red and getting bailed out. Almost all hospitals are non-profit. About 40% of NH spending. SP makes this even worse by eliminating forever the risk of bankrupcy.
In what sense? What do you like about KP: the doctors, nurses, etc.? The billing department? Single-payer would not take the staff away. It would get rid of large swathes of the billing department that are pure waste.
Not everyone has had your positive experience with KP. We switched away due to lack of availability of certain specialists.
*edit: spelling
https://www.washingtonpost.com/national/health-science/why-v...
>As with any attempt to dismantle one American health-care system and replace it with another, Green Mountain Care was always going to be a long game. For starters, it would not be until 2017 that any state could get federal permission to change the way it used insurance subsidies created under the ACA.
Did they repeal the tax increase?
"Doubling my taxes?!"
Oh... for a CA based single payer healthcare system that for the last 10-20 years people have continually asked for again and again? (Ok, maybe not just for CA, but... sometimes ya gotta start somewhere)
So now I'm back into the evaluation phase after headline whiplash. Will definitely consider the 'total compensation package'.
The headline is no accident, The Tax Foundation is a center-right, fiscally conservative organization, generally critical of tax increases.
I was shocked to learn how much my parent's insurance costs.
Even though ostensibly employed by a huge multi-national, my dad technically operates as his own S-corp so they have to buy on the market. That seems to be a trend in the gig economy which is worse for low 'wage' earners.
I also am on private market as I own my business. Mine is $500 a month at 32 and healthy. Theirs is 2k ish and increases significantly each year (65 and 62). That is really hard for almost all older Americans to afford. By the time they are 75 or even older the cost would be insane if this continues.
I agree that messaging is what's holding back reform. The messaging is so easy to short circuit. Just look at the headline of this post. No one wants their taxes to double.
That's more or less why Medicare exists.
But still a lot of out of pocket costs and premiums if you want drug coverage and more.
Correct me if I'm wrong but it doesn't really cover if you need long term care which is insanely expensive.
Also, private stock valuation can't simply pay health insurance bills.
Then again, with many wage-earners already leaving the state, this may turn toxic.
Overall I think a single-payer system is for the best. Having healthcare tied to your job creates another anchor to keep people tied to large, stable companies instead of taking risks with startups or small businesses.
The main downside is that companies have started doing tiered healthcare costs based on things like smoking or health indicators. Having income tax based on your weight or smoking status is probably a non-starter, so it removes some of the incentives for people to make good choices (and reduce healthcare costs).
80% of people with Type II diabetes who are also overweight or obese would be asymptomatic if they lost weight. Why spend public money if there exists a free treatment? Save the public resources for right-weight type IIs and type Is.
Speaking as someone who has lost over a 170lbs…it ain’t eas. It is the hardest damn thing I have ever done and your body fights you every step of the way…forever. It never ends—for the rest of your life your body is constantly fighting you to get back up to the weight you were.
Also, your concept of preventing all other treatments until someone loses weight is absolutely barbaric.
If you were obese and now are not, I applaud you. But I also know it wasn’t easy for you to make that change. I used the word “likely”, because it felt to me like you communicated in a dismissive and nonchalant manner, like someone who hasn’t gone through the difficulties necessary to do it.
You also need to consider that a sugar tax can hit lower income people a bit harder.
It cuts in many ways: save money and gain health by drinking water/tea/coffee instead of softdrinks. Use the money for healthier foods.
Elections have consequences. Try un-electing your group plan provider.
Yes, you can.
And you get a vote on who is running it, too
Australia has very high taxes on cigarettes mainly because they want to keep their (universal) healthcare costs down. They could do the same thing to sugary snacks as well, even the conservatives would get onboard if it was to save money on healthcare expenditures.
It's designed to be a progressive system, unlike current health insurance, so almost nobody's change will be net zero, even assuming the cost of providing the service is the same (which, who knows). Low-income earners can probably expect to pay considerably less, and high-income earners can expect to pay considerably more; only people right at the crossover point would expect no change.
No thanks. We're moving. More real estate and jobs for the rest of you true believers. Enjoy the weather. I will miss it.
California has benefited from the Federal spending bonanza and also has famously high tax rates, treats capital gains as ordinary income, and has a lot of rich people. The FTB seems to have screwed up the links[1] and I can't find later data for a complete fiscal year, but check out "Ordinary Dividends" and "Capital Gain" in exhibit A9 for FY2019[2] to get a sense of how important that is to the state budget.
[1]: https://data.ftb.ca.gov/stories/s/Other-Tax-Data/sgxz-494k#d... [2]: https://data.ftb.ca.gov/download/d6s8-gyup/application%2Fpdf
I love this state’s geography and food scene, but the various governments here (local, county, state) aren’t exactly the pinnacle of smart governance.
This is from an advocacy organization that is more or less anti-tax. There are probably much more balanced takes on this proposal from other sources.
Have you done this analysis? Most employers cover a portion of your employer sponsored health insurance. Are you expecting that your employer will just add this amount back to your salary?
At no point in my career, going back to fast food in college, have I ever spent 5-10% of my income on insurance. I would have to include the employer portion to even get close to that.
When you are the single payer for the entire state, yes, I think the doctors in the state will take it.
I have a lot of complaints about my government (like most people), but the idea of universal healthcare isn’t one.
- Employer-sponsored healthcare is aggressively anti-entrepreneurial and any universal program would be a massive boon to independent workers and those who own or want to start their own business.
- In addition to the $400-$600 us and/or our employer pay every month (for one person), we also have to pay for copays, coinsurance, deductibles and so on. I'd hope that under any universal system these would all disappear. And no more HSAs and other unnecessarily complicated programs we've designed to deal with our bizarre system.
- CA already has a variety of healthcare systems that are universal for those who qualify and are very expensive. I'm curious how these might operate under a statewide universal system, especially fully federal programs like the VA.
- More than anything, I'd love to leave behind our byzantine and unpredictable system of trying to determine which providers accept our insurance (goodbye "networks") and how much a given treatment will actually cost us. Even as a person who does not often need medical care, I've still encountered many unexpected bills, in some cases despite direct assurances from the provider and/or insurer that I would not have to pay. Then comes the appeals... another absurd aspect of out system we could leave in the dustbin of history.
Can't emphasize this too much.
I'd rather start a small startup of my own, but the only thing that always keeps me away is health insurance in the US. I have enough savings that I could afford to pay all my expenses for many years so I'd be comfortable with no revenue for a long time.
Except for health insurance, which currently is $2500/month through company group plan, surely even more expensive for a new tiny startup. Can't do it.
I guess I need to wait until I qualify for medicare to try my hand at my own startup.
However, as a California resident who has seen this state's inability to think through regulations effectively or solve housing problems, I'm incredibly skeptical of California's ability to implement single payer healthcare effectively.
I would likely leave the state because I assume California would fail to deliver, and taxes would get raised for nothing.
In what universe are these things a coat of paint? In California's economy, these things are the whole damn tree: the roots, the trunk, the leaves, all of it. It might have a couple rotting branches, but it yields so much fruit that people just don't care.
What California has is not the norm. Other states and countries might have one of those things; maybe they've got ports, or maybe they've got farmland in an optimal climate, or they've got something else. But until things change (which they will), no one has been able to have Hollywood or Silicon Valley as well as everything else. Once those things are sufficiently dissolved and others drink from our milkshake, it will suddenly be apparent how few of the people in California cared, to use your words; when the money dries up, it will be apparent how few things we actually have better than other parts of the country, as well as other countries. It's easy to ignore outdated and crumbling infrastructure, the crime and the homelessness, and budget being utterly wasted when the money keeps rolling in and the beach is no more than an hour away.
Isn't the whole point of a single payer system putting and end to this madness? You no longer need to worry about a doctor accepting your insurance, because there's only one insurance, and everybody accepts it. (You can still buy additional insurances if you're worried about a medical disaster, but that's a separate concern.)
But to answer your question, sure, there will be always a market for the select few for whom money isn't a concern. The difference is that, under a single-payer system, you don't have to worry about it: just find a doctor at Yelp, or let the ambulance drive to the nearest hospital, and your doctor and your hospital is covered. You will intentionally have to go out of your way to find your boutique doctor who doesn't accept "dysfunctional government insurance."
This is very important, because when your kid is bleeding inside an ambulance your concern shouldn't be "Wait but does this hospital accept my insurance?" You have a bigger problem to worry about.
My only hope if we do this is that the federal govt or other states do not leap quickly into this and give it a good 10 years to see how things work out for us.
https://turbotax.intuit.com/tax-tips/college-and-education/t...
European countries (including the UK - actually one of the best examples of single payer health care) figured out that having a healthy population is a matter of national security, so it gets funded the same way.
Do you have any knowledge of what the typical waiting periods are in the US? How many are postponing care due to inability to cover the costs?
I happen to think the UK is not close to the best example.
These are for what in the US are considered relatively routine and available services - things like a pacemaker. Or knee and joint work.
“The pain is so bad now I don’t want to live much longer,” she explained. “I get up in the morning [and fear] making it to the bathroom without wetting myself as the pain and stiffness overwhelms me. Then, after losing my dignity, I attempt to make it down the stairs."
So we need to begin with just the basics - can you even get care at all - period.
Your employer can't "take away" your health insurance in the US in most cases. If they will stop paying for it in most cases they will send you a letter giving you the option to pay for it. This will cover you for up to 36 months.
What you would do is after being laid off is to take advantage of the downtime to get LOTS of care. That's actually pretty common approach, folks max out benefits for 1-3 months then let COBRA coverage drop. I've seen some folks take advantage of the 60 day period to decide to basically go get tons of testing, if nothing comes up they let it drop after 30 days. If they expect lots of costs they keep coverage.
Alternatively, a layoff is a qualifying event. You can sign up for subsidized coverage on the obamacare exchanges. For an individual this helps with incomes < $51K, and households of 4 < $106K. For example, if you still have SOME income coming in (let's say $20K per year) you'd do something like a Silver 87 plan. That runs about $3/month.
Alternatively, if you fall below certain thresholds in income (ie, laid off with nothing) you would be eligible for medicaid for adults. For an individual this kicks in for incomes below $17,000.
I can tell you it's pretty grim looking at a crippling illness and trying to juggle employment so that you might have a hope of managing that illness. So yes, I hope I'm wrong but so far it isn't looking so good.
Single nondisabled male adult - not in mandatory medicaid coverage groups unfortunately. That said, many of these types of states are are aggressive about offloading to disability. Depending on your circumstances than can be a route to medicaid as well.
Also, coverage is rationed more in these systems, they would never approve these the $20,000 per bill with limited evidence type treatments.
It's a huge step up for everyone that is unemployed or on crappy minimum-wage insurance. Even if it's "only" on par with the worst of the US system, it still grants you the freedom to switch jobs and a better negotiating position for other benefits. And everyone that has better insurance can presumably just pay out of pocket to get better-than-minimum.
NHS in the UK has 6M folks on waiting lists for things like cataract surgery, knee replacements etc. The wait time is in range of 18 weeks for many and for 300K+ > 52 weeks.
Private providers in the US will see you MUCH more quickly than one year (!!).
Some place like Europe are not really single systems. They do work well though in a lot of ways.
They will have statutory mandated and the private coverage. Even the mandated coverage will be delivered by 100-200 nonprofit funds. "Government has virtually no role in the direct delivery of health care."
So these systems work by a) requiring that everyone be covered and b) staying out of the way of the actual service. Interestingly in germany patient representatives have no vote on the main body handling this (insurance companies and physicians do).
And for anyone privileged to be able to afford good insurance in the US, you can presumably pay for better private insurance/service in Europe, right?
Places like Germany have taken a very different approach. Govt stays out of delivery of care entirely, but everyone has coverage basically (80% public/20% private maybe).
Public care is pretty good with low waits. But govt not delivering it.
The obvious question here (and I legitimately don't know the answer) is if there are a bunch of people who want knee surgery in the US but can't afford it, and so demand at the offered price is lower.
Fewer people being able to afford a procedure would generally mean less demand and shorter wait times, but its not clear that that's a preferred outcome at a population level.
Switching to a single-payer will be too costly for any political party to tolerate. The US spends $3.8T on health care per year. That's $11,500 for every single person in the United States.
In order to fund (raise taxes) to a single-payer system that number will need to drop dramatically. We'll have to cut out middlemen, reduce bureaucracy, negotiate domestically, etc. That $11.5k needs to drop to about $6k to be on the upper quintile of health spending per capita compared to other, successful, single-payer systems. That brings the total from $3.8T down to $1.98T.
...but therein lies the problem. The health sector is 18% of the economy and employs 14% of all US workers. You can't quickly pull $1.8T out of a single sector of the economy. Would it stabilize to 9% of the economy and 7% of all US workers? What do all those people (7% of all workers) who previously worked in health care go do? Where does that $1.8T that we used to spent show up?
So it's a conundrum. You need to slowly reshape the industry over 10-20 years and carefully manage the outcomes or it's an economic and political disaster. However, the only way for that gradual plan to work is if you raise taxes to fund the $5T that it would take to maintain status quo. ...and good luck with that. The total net worth of all the billionaires in the US is $5T. There isn't a tax rate in the world that could raise that kind of revenue.
Vermont tried to implement a single-payer system, did their own analysis of what it would take, and decided not to move forward.[0]
So it's not that I oppose single-payer in theory, I just oppose it as policy in the US because I see it as a political impossibility that is in the way of realistic reform. To me it's chasing a perfect outcome when there are good outcomes available.
[0]:https://www.vox.com/2014/12/22/7427117/single-payer-vermont-...
But I agree in general: healthcare reform should do something about costs, and healthcare is so much apart of our economy that any attempted cost reduction will be painful.
Presumably the entire industry isn't going to magically become less complicated when a single payer option begins. There will still be a need for many of those roles, but they will be employed by the state instead of private companies siphoning profit.
I have not seen, and I am not sure it would be possible to generate, evidence in the number of jobs that would be lost (or created) by a single payer system.
People complain all the time. The military budget is $700 billion. Healthcare expenses would be $5T to cover everyone in our current situation.
For reference, the total federal tax revenue is $3.86T. That’s individual, corporate, payroll, everything.
> Presumably the entire industry isn't going to magically become less complicated when a single payer option begins. There will still be a need for many of those roles, but they will be employed by the state instead of private companies siphoning profit.
Yes that’s the exact problem. How to not destroy millions of lives and the economy. You’re suggesting these people will go work for the state? We will literally have to, at minimum, double the effective tax at every single level. Double the federal income tax, double the payroll tax, etc.
Would you personally vote to double your total effective taxes? I would not.
Single payer just isn’t going to happen in the US anytime soon. Democrats can’t even corral the votes to fund an infrastructure bill that is a fraction of the cost an single player health plan would cost.
…and Democrats are going to get thrown out of Congress this year. So it’s time to move on to reforms that might actually happen.
Or we can keep endlessly chasing the perfect outcome and endlessly achieve nothing.
Regardless of its effectiveness, single-payer is not the norm in "most European countries". Americans naturally get exposed most to the UK and Canada and so think that their single-payer systems with zero/minimal cost on delivery are what "everyone else" uses, but it's not true. Germany, Austria, Switzerland, and the Netherlands are among those that mandate getting one of dozens/hundreds of private plans (basically Obamacare without exemptions). Australia has a government-run plan, but *strongly* encourages people to move to private plans. France has three big nonprofit plans for the entire country, with 30% copayments (akin to a US high-deducctible plan, without the corresponding HSA). Etc., etc.
Healthcare benefits from having a larger population, and it is harder to provide quality care for a smaller population (read more expensive). Yet Finland spends less per capita and has better outcomes.
Nowadays it means "We can't have a single-payer system, never mind all other first-world countries have it, because this is America!"
Mathematically, the extent to which it happens and the duration don’t make much sense to me.
CA lost population in 2020.
USSR has learned this lesson 100 years ago and paid dearly for it. I wish people could learn from the past mistakes rather than repeating them on their own...
Breathlessly comparing the USSR's economic policies with the raising of taxes to cover such a fundamental service betrays a staggering ignorance of economics and history.
Russian culture is very similar, so when USSR implemented centralized planning, people resorted to just stealing what they could. Like literally, your way to get some meat for the lunch would be to know the guy that works on a sausage factory, who would steal a piece for you in exchange for some vodka your cousin stole from the distillery. This eroded the trust between people to the point where you cannot start most types of business because your employees will randomly steal shit from you no matter how much you pay them. Hence, high petty crime. Hence, endless feuds between neighbors. You have no idea how low the ship can sink without people realizing that something is wrong.
What always worked in the entrepreneurial cultures like the American one is set proper incentives. Simple, transparent rules that people would agree upon, and let them compete with each other. If you have 10 dental practices, and 2 of them charge you for the holes you don't have, the customers will move to the remaining 8. If a hospital starts charging unreasonable fees to feed extra levels of bureaucracy, a bunch of pissed off MDs will open a competing one. But we are not doing that. We have low interest rates that allow established players to scoop up competition with cheap debt. We have complex bureaucratic systems that make opening a new hospital without a 8-figure investment virtually impossible, and then we wonder why people's entrepreneurial energy gets directed towards creative billing rather than actually delivering value.
Your analysis is complete bunk.
That's what it was reminding me of. (The USSR comparison should have given it away, but I can be slow that way.) Complete with the farmers going all "John Galt". Of course, what Rand forgot was that there's not going to be pitchforks at the granary. Like, what, folks are just going to let that land lie fallow? Like there isn't going to be some other steel company glad to have the competition out of the way? (re: Atlas Shrugged) Some folks like to fantasize that the world will miss them when they take their ball and go home. Some will later discover that the world is cruelly indifferent to them.
Looking at California's continuously rising GDP, it is hard to believe that value producers are leaving to be replaced with leaches. More likely, conservatives have been leaving the state, but since they live in more rural areas anyways (i.e. the red parts of the state), it hasn't dented the state's GDP much.
> It will work just great until suddenly there's not that many value left to feed all the hungry mouths. And then the mouths will take pitchforks and go raid the nearby granary because that's where they think the food is.
Ah, is your statement more about immigration from Mexico to support California's huge agriculture industry? If that is the case, then I agree: ever since Trump cracked down on illegal immigration and then with COVID, it has been really hard on Californian farmers.
That has been the fantasy of many for at least as long as I've been able to read a newspaper, which is going on 50 years. And it never really seems to happen. Sure, there's a year or two of net migration out of the state, a few companies actually do leave, U-Haul reports that there are no rental trucks in the state of CA, they're all in $ANOTHER_STATE.
Then a few years later, house prices keep going up and net population rises. Maybe that big CA housing crash might actually happen this time, I dunno. I'm not counting on it, though. (Or for that matter, I'm not even caring, as we rejected moving to CA many years ago, and taxes are certainly a factor in that decision.)
The idea is to stop paying health insurance to private insurance companies, and replace that with state taxes that pay for all health care instead.
Depending on your income level, the most likely outcome is that you'd see very little change in your overall compensation, plus your health insurance would no longer be tied to your job.
If the latter goes to zero and the former goes up, that's not actually doubling my deductions, despite the hyperbolic headline.
This part seems insane. Any business with slim profit margins and out of state competitors is screwed.
Also, does this mean multi-state/multi-national companies have to pay 2.3% of their nation/world-wide revenues to California? That's obviously absurd...
So as not all is BW, from my experience with Canadian HC, socialization of the health-care system shall produce the following: 1. significantly lower the quality of services (same or lower number of staff, material, equipment serving higher number of people) 2. waiting lists shall start appearing slowly and then progress over the years 3. HC shall deteriorate slowly (look at the UK and many other countries) 4. Extended/add-on/"bridge" HC shall become popular to fill in the gaps for the working people who demand at least better minimum (in Canada this is the norm, where typical Canadian pays just for this add-on HC similar per paycheck amount as US employer for the whole today's HC!)
Populist government "figures" shall play any card to live for another day and "please voters" including "changing realities" or avoiding the real "put all on the table and have open conversation" approach.
I don't know if most people realize it, but there is definitely a tradeoff between 100% equal access and quality. But it does seem that's a tradeoff that many people want to make so idk
People vote for "short term sales pitch" instead of what is optimal and right for long term and their kids and grandkids. Key factors are missing: - Political manipulation is dominant. - Fact, logic rational based dialogue is vanishing. (i.e. indirectly and directly stimulated by interests, so left does not talk to right and any rational thought is attacked/labeled/censored and anyone who provides criticism of any or both sides in different ways is painted/pushed "polarized" often each side paints such people both ways whatever suits them, so echo chamber effect gets amplified until the system blows up). - People, through generations, are conditioned to be driven by emotions vs face logic/facts/rational. This starts from the early age kids conditioning them into 'ideal consumers' (some call this "idiots" and I understand it but it will be hard to wake them up by reason only, as past tells the only unfortunate way to wake up is catastrophe/calamity/hinger/war)
I can tell a lot of information to anyone that can be add on to Michael's Moore documentary and can paint the complex truth. It is not black and white at all and from my long life experience, best would be to fix the current US HC by breaking monopolies and unfair practices (such as price gauging, etc,...) and this could get US to way better HC than any socialized system can be. But my predictions is that "populism hustling" in the atmosphere of forbidden rational dialogue and political hustlers will go worse direction. I guess it is that 4th degenerative phase of the empire, where "soul&spirit" of the people's mind falls (obvious all around us). I just hope US does not go the way of Balkan.
It should also produce better health outcomes for the people living there. Maybe you have a well-paid job and good insurance plan, and can enjoy good healthcare now, but that is not the case for many others and can change for you if you are unlucky.
Even a very poor country like Cuba has higher life expectancy than the US. Most developed countries have better health outcomes than the US, while spending way way less on healthcare.
There may be deeper causes for this beyond the privatized healthcare system in the US, such as the legalized political corruption (lobbying, PAC's) and litigation law leading to huge overhead costs in everything. These will be even harder to change.
To remind ~150K earners pay ~50% of CA taxes.
Let that sit in your mind 1st, then ask yourself if ~1/2 of those flee to where it is better for them, the effect is and can only be either or both; worsening of health care and/or further raising the taxes. This is known effect that happens. Major HighTech companies are disincentivized and are already taking difficult decision. The question is when the avalanche effect happens? If it happens or if it is gradual race to the socialist bottom, then you can moralize 'til the cows come home, but guess what they won't be coming back.
Silicon Valley CAN become Detroit and it is already on initial phases of the path in that direction, although still far. Capacity of derangement of the CA government is not yet reached and ~70% Blue is not making any constructive dialogue to balance things here.
I am high earner and for a while I can bear still ok health care here and then I could enjoy early retirement (i.e. freedom 55) with this new socialized HC while it is still "ok". After a while I guarantee it will go worse and even I will be forced to re-evaluate and possibly move.
So you think it is moralizing to take people and fairness as the fundament? I certainly prefer that over numbers, if that makes me moralizing then so be it.
What you are implying is that you think the janitor (not an employee of course) of that hightech company who can't afford insurance does not deserve treatment when she gets hit by cancer. Paying for that would be too disincentivizing for the employees and shareholders, and the company should consider moving to another place that is more considerate of its needs.
I think the whole idea of poor people getting the same healthcare as rich people is really what is putting off many people in the US. Even if it would be better for everyone and have no downsides at all, it would still face opposition.
Let's take it at face value this is fact.
For my healthcare plan I pay 6k a year on top of what the company pays (more that 20k). Then I pay copays on top of that.
It seems perfectly plausible to me that I would come out ahead if the company and I switched from paying about 30k a year in healthcare costs to a single payer system with only 20k a year in costs to me and my employer!
We can split the difference and each is ahead 5k.
I think people need to do more than just read a headline.
There are a lot of details in that to sort, and no-one expects a final single-payer system to wind up quite as good as Medicare is... but there is a lot of fat to trim off the private insurance system.
And note please: we are only talking about admin fees (salaries and the like for people working there), this has nothing to do with the actual costs of care. If anything this is unfair against Medicare, since they are ruthless in negotiating their actual costs (something private insurance is not really incentivized to do at all).
If you don't like the switch from private bureaucrats to public bureaucrats then please state that and make your argument why. Don't pretend the private ones don't exist.
I, personally, am very happy with my employer health insurance and am glad that I left CA for a state with no income tax, but for the people remaining in CA it sounds great.
If this ends up happening Americans will have the ability to choose to live in a place with universal healthcare or not while still living in the US, which is pretty cool IMO.
California is nation-scale. You are still forcing this kind of system into a nation-amount of people.
I assume it would also be restricted to Cali without procuring a reciprocity agreement with a national insurer.
If Dems managed to repeal the SALT deduction cap OR Cali just codes it to get around it (payroll tax direct to company only, and independent contractor business tax), this would be a much better idea.
There are no national insurer btw, except for self insured employees.
Per capita income in past 12 months (in 2019 dollars), 2015-2019 $36,955
https://www.census.gov/quickfacts/fact/table/CA/INC110219
Your median Californian, and significantly above your median Californian, makes below $250k.
Last year I was able to choose my surgeon who operated on my knee last year and my total out of pocket expenses were less than $500 for a $20k surgery. In most single-payer health care systems I wouldn't have been able to get the surgery because it was elective and only a partial tear of my patellar tendon.
Healthcare costs and outcomes can't be separated from each other. The more expensive it is to receive treatment, the fewer people will get the treatment they need. Having good service isn't sufficient if that service isn't available to everyone.
[1] https://en.wikipedia.org/wiki/List_of_countries_by_past_life...
For example, I had a knee surgery for a partial patellar tendon tear last year that cost me <$500 out of pocket (insurance was billed $20k) and this surgery wouldn't have been covered by any single payer health care system.
I'm happy the American healthcare system worked well for you. And I'm sure there's plenty of people in Canada who've had terrible experiences with their healthcare system. But that doesn't change the fact that the average Canadian has better health outcomes then the average American.
The American healthcare system fails to support many people most needing help. The fact that the richest country on the planet doesn't provide adequate healthcare to everyone is an embarrassment. Something needs to change, and I refuse to believe that we can't (or shouldn't) provide world class healthcare to every American.
That is debatable. I have the top-tier plan my employes makes available (blue shield platinum). It's $2500/month.
That still doesn't guarantee anything, if the insurance company doesn't feel like paying it because it cuts into their profit margin too much.
Right now I've been prescribed some medicine I need to heal some damage and I can't get it because insurance company says "too expensive, we don't feel like paying for it, sucks to be you".
(Wrapped in many pages of legalese, not those exact words.)
> In the US system you have the luxury of choosing your providers and having your insurance cover things
Well no, not really. If you mean chose between gold and platinum levels offered by employer, ok, but that's the extent of the choice.
I'd like to choose an insurance company that gives me the medicines my doctor prescribes me. But no, I have no such choice available.
Ideally we should just have an open private insurance market where you shop for whatever insurance you want and your employer pays some part of it or reimburses somehow. Imo this would drive competitiveness amongst private insurers the best and give everyone their best plan.
With that said, I prefer private insurance over single payer because I’ve had good experiences with my insurers so far. I am one of the lucky ones though
* availability of a wide set of health procedures
* median time to delivery of a given health procedure
* outcomes from specific medical conditions
* expected longevity, measured at various points at or after birth
* cost of a given health procedure
* median proximity to health care facilities
* percentage of population without access to a given level of care
* ...
Gonna stick in PA with our 3.07% while I am earning bank and healthy though.
Same with e.g. homelessness solutions.
Of course, even if the proposal becomes law, it might take a decade or two to come into full force (someone else mentioned CA's High Speed Rail project, but healthcare as it exists today is a far larger Gordian Knot), so I think I'll watch from the sidelines to see how such a grand plan works out in reality.
(This is not tax advice, I'm not a tax advisor, etc.)
However literally true that might be, the chance of the amendment being passed by voters seem neigh-zero. And the article seems to carefully avoid that subject.
So file this one in the "if we had a metal which could easily contain the temperatures and pressures needed for economical hydrogen fusion..." bin.
Who knows what's next. Perhaps this will help the bullet train reach Fresno, Merced, or maybe Modesto. By 2050. Maybe.
In San Francisco Bay Area, it's even more stark. There was a 45% decrease in entrances from other states to the Bay Area and a 21% increase in residents leaving for other states.
I'd hope most of us know better than to try and make arguments like this about once-in-a-hundred-year historical anomalies.
Other states are seeing the exact opposite.
It's an adverse selection problem.
People who are most subject to the tax are inclined to leave.
People who benefit the most from the trade are inclined to move in.
This potential tax hike would probably be the proverbial "nail in the coffin" to the state of CA. Just for us we would see our taxes go up the equivelent of doubling our mortgage payment, that is complete insanity and I would expect 80%-90% of all the high earners to flee the state causing its finances to drop off a cliff.
If your net take-home pay goes up (or even stays the same), why would you care if the line item called "CA tax" goes up while the line item called "health insurance payment" goes to zero?
Covered CA is the ACA exchange, not a public low-income plan.
Mine (blue shield from a silicon valley employer) is more than that (~$2500) every month.
The headline hints that families would be paying those additional taxes, but if you read the details most of the additional taxes are on companies (and the best points that the article makes are about how those are structured in ways that may not make sense). They are trying to mislead you to be outraged in the headline, and it worked.
So the taxes that you and your employer pay would increase (that is what the headline is saying), but much if not all of that would be offset by the costs that you and your employer are currently paying.
The first sentence: >>A proposed constitutional amendment (ACA 11) in California would increase taxes by $12,250 per household, roughly doubling the state’s already high tax collections, to fund a first-in-the-nation single-payer health-care system.
It completely omits that this move would simultaneously remove every resident's healthcare & insurance costs.
Pretty obvious bad-faith writing, and it is disappointing to see it echoed on HN.
Edit: I'm happy to read about and discuss the merits and problems of such a proposal, but this kind of title is just irritating - it's what I try to come here to avoid.
Many people here are arguing that healthcare is expensive, is a basic human need and it's really hard to get it in the US if you don't have a job paying for it. Even when jobs help out with the premiums, it's still hard to pay for it in California. All true.
Do you know another basic human need? A place to live. Without a place to live, you are homeless - which is normally seen as even worse as not having access to healthcare.
A place to live in the bay area is really expensive, more so than healthcare. I don't live in the bay area, but it appears that a reasonable rent for a place for 3 people is around $3500/mo or 42K/year. This is more than out of pocket (no subsidies) Kaiser + average healthcare expenses.
If the government is supposed to pay for healthcare in California, why isn't it supposed to pay for rent? Both are basic needs and quite expensive. Serious question.
I don't think there are any taxes anywhere that help "everyone". I don't even think there are any taxes anywhere that help "everyone" in a specific jurisdiction.
I've never heard a solid argument against the public option and both sides in general seem to agree on it. The fact that it was Lieberman and not a Republican that killed it in 2010 [0] makes me very hopeful that a public option would be highly politically viable now 12 years later.
[0] https://newrepublic.com/article/73683/the-public-option-stil...
But you are of course correct in France having private doctors and hospitals as well as public hospitals. Speaking as an American, city17 makes the common mistake of thinking that Canada and the UK, the two foreign countries we are most exposed to, are representative of the rest of the developed world. Since both countries have single-payer systems with zero/minimal cost on delivery (and more or less 100% public hospitals in the UK), many Americans think that that's the way all countries' healthcare systems work. They have no idea that a 30% copay is normal in France, or that Germany/Austria/Switzerland/Netherlands all have Obamacare-like mandates to obtain insurance from one of dozens/hundreds of competing plans, or that Australia has a government plan but *strongly* encourages people to get a private plan.
"CA considers publically funded health care" would be just as accurate.
please fix this.
> For instance, the payroll tax exempts employers with fewer than 50 resident employees, punishing small businesses for expanding and creating a meaningful tax cliff. Imagine, for instance, the overly simplified hypothetical of a company with 49 employees making $80,000 each. At 49 employees, the company has no payroll tax burden. Hiring one additional employee generates a tax bill of $90,000—more than that employee’s salary!
Wow! NINETY K, MAN! That's a lot of money, says Joe Q Public.
Except....revenue per employee is ~$100k for small businesses, with larger companies being $200k or more.
At 49 employees, your business has likely $4.9M in revenue or more.
That means that additional big scary $80k represents 1.6% of your revenue.
Yawn.
Otherwise, I don't see how middle class will not revolt and leave the state.
So glad I'm not a californian lol.
Like these are failed institutions kept alive my the infinite tax payer money faucet. Turned this socialist into a capitalist in just 25 years. Government is absolutely hopeless on execution, but great on selling the vision to people with no experience in execution ... e.g. me at 25.
Every tax that California adds risks killing that golden goose. Tesla has already left as highly publicized, but others are too. Apple is building a billion-dollar campus in Austin, Texas. Oracle has moved its headquarters to Texas.
That they're already seriously regretting doing now that the promises of the remote economy are starting to be truly realized and the pandemic shows no end in sight. Billion dollar campuses are worth $0 in a fully remote economy. Turn them all into high quality public housing and move on. The office is dead.
If this is as it sounds, my future is definitely not in California.
For those following along at home, this resolution would take the form of a Constitutional Amendment, if passed by Californians on the ballot that would raise per household taxes by $12,500/year. The important thing here is that Californians have to agree to pass it.
$500,000 income (at 50+ org) would be taxed $7500+4500+750+2000 = $14,750/year
$300,000 income (at 50+ org) would be taxed $3750+2500+$750 = $7000/year
$150,000 income would be taxed either $1000 (<50 org) or $2875 (50+ org) a year
$50,000 income would be taxed either $0 (<50 org) or $625 (50+ org) a year
So it's around $450,000 income that you hit that $12,500/year amount (2.7% of income)
Excise tax is separate factor.
Lots of devils in lots of details, of course.