NY Senate Bill S5474 proposing a universal single payer health plan for NYers | Hacker News Reader

NY Senate Bill S5474 proposing a universal single payer health plan for NYers

nysenate.gov

358 pointsKoftaBob543 comments

it will be interesting to watch NY (and/or CA) put something like this in place and observe from afar. i strongly feel that states should be much more aggressive running policy experiments if their constituents desire them, and at the national level we all get some benefit of seeing how things turn out in real time.

all that said, assuming there is some tangible tax increase, NYC high earners are going to be knocking on the door of 60% combined rates (city, state, federal). tax avoidance and/or relocation services are going to be booming if so.

Remember that this expense is also reducing the cost of employers.

One of the best ways to finance this would be a payroll tax that is basically equal (in aggregate) to the insurance the company is (usually) already paying.

If you think employers will share the savings with their employees, think again.

I don't think they're saying that at all. I think the point was, a payroll tax won't necessarily increase costs for a company because it would be offset by eliminating the current healthcare costs.

Right, but my point is that to keep the relative advantage they’d have to pay.

For example imagine a company attracts talent by paying median + healthcare, and another that just paid median. For the latter they would have more costs, no?

The savings aren’t offset unless they were already offering the incentive.

Yes! The private-insurance-mimicing payroll tax is by far the best path.

Nobody is going to believe that there are savings to be had, so it's best to start by reducing friction.

Only because people are conditioned to only seek medical attention when it's absolutely necessary, because it's too expensive to be proactive even with insurance.

Big employers like having health insurance tied to employment. It makes changing jobs a riskier maneuver for employees as they do not know the quality of the other jobs' insurance coverage, and it creates higher overhead costs for smaller employers so it provides a competitive advantage there too.

> they do not know the quality of the other jobs' insurance coverage

And the fact that you can't actually take time off of work to pursue a career change or look for a new job, because you need your job in order to be able to afford basic healthcare. Which makes it a lot harder to pursue a career change or look for a new job, because you are stuck/busy at your current one + whatever other life responsibilities you have (not to mention the really high commute times in NYC).

I mean, they can lobby against it, but other than that, what does it matter that they don't like it? It's not like they are so management heavy that they can swing a vote.

They won't have much of an option. I don't see them closing up shop and leaving NY if the talent is there.

I do, the talent exists elsewhere cheaper

No it doesn't. If it did, they would already hire those people and get rid of their more expensive talent.

Those people are not applying because they live elsewhere. If they moved they would have a different candidate pool.

Pretty specious argument in the days where SF companies are mandating RTO when it could be far cheaper to negotiate to WFH status those employees who didn't want to be in the bay area or bay area offices anymore.

It isn't just talent, it is local ecosystem.

Large metro areas have a large # of services available. From office furniture delivered in hours to a wide range of service industries available on demand.

From food delivery to sign printing to courier services, large, dense, cities have economics of scale.

> a payroll tax that is basically equal (in aggregate) to the insurance

Whereupon there is no reduction in cost to any employer.

Theoretically there could be a reduction because the state would be a larger pool of cross-subsidization than any particular employer. In reality the costs are worse since the state will use the taxes to subsidize non-employed persons.

There is nothing stopping NY employers now from just giving people enough cash to buy a plan on the ACA marketplace. You're assuming this upcoming plan will have offerings employees will want, and charges employers whether or not this is the case.

NY should pay for single payer in part by raising real estate taxes, it's the only clear way the state has to avoid capital flight in the way you're describing here.

This said, a big thing NY benefits from is that a lot of people work in NY state temporarily as consultants in addition to the bridge and tunnel crowd that come in from NJ and CT, this gives them a much larger tax base than the population living there brings in on its own.

I live in NY and pay >$18k a year in property tax for a small house. Real estate taxes are high enough.

They are offensively low for multi-million dollar buildings in NYC. Cut some slack for owner occupiers who had the assessed value skyrocket on them. Tax everybody else fairly.

A part of the reason is idiotic programs like 421a

"Fair" is highly subjective and no one can agree on what that means. Most of us think the fair option is to raise other people's taxes.

"most of us" don't understand the basic concept of marginal tax rates, and "most of us" don't understand the idea of marginal utility. "most of us" have in some form or another been doused in a firehose of "the only good tax rate is a lower tax rate" propaganda generated over (at least) the last 40 years.

For a long time, the USA (like many other post-industrial revolution countries) has accepted that "fair" means using progressive taxation to try to create roughly equal impact given the marginal utility of higher levels of income. It's not incredibly scientific, but it isn't really incredibly subjective either.

Conservatives and their cousins at some level more or less reject the concept that there is any fair level of taxation at all, and if there is, they lean toward equal numerical taxes for every dollar earned (or taxed), thus rejecting marginal utility theory entirely.

There are at least a couple of high-net-worth-admission lobbying groups that have asked Congress to raise rates on people like themselves (which inevitably will impact other people like themselves). And speaking for myself, I believe that I should pay more in taxes.

Most of us understand the concept of marginal tax rates just fine. We're arguing about the optimal shape of the curve. Everyone (with a few exceptions) seems to prefer that the curve should trend up sharply just past their own income level.

At least half, and I would say as a hand-waving number, maybe as much as 75% of the comments I see in any online comment thread to any news-y-ish thing demonstrate a complete failure to understand marginal tax rates.

Closer to home: my kids don't understand it. My wife doesn't understand it. Most of my in-laws don't understand it.

> the only good tax rate is a lower tax rate" propaganda generated over (at least) the last 40 years.

You lost me here. I guess it’s bad to want to keep my money I’ve worked so hard to earn. Must be that propaganda. Or perhaps the socialism propaganda just isn’t working?

If a property sells for $10M and it's assessed at $100K that's objectively unfair. NYC's deficit spending means that their intentional under taxation of property is subsidized by the rest of the state.

How would raising taxes on real estate not cause capital flight?

You can't move a house (or the land it sits on) out of state.

I can't tell if you're being serious - but when people start moving out because of excessive taxation, prices drop and tax revenues go down with them (because real estate taxes are based on home values).

Capital flight lowers real estate tax revenues. This should be obvious, so maybe your comment was a joke?

FWIW, in NY generally the tax assessed value of properties is far below the market price (20-30%, sometimes more).

NY could afford for the "market price" to fall quite considerably before it would significantly affect tax revenues.

Land value tax. Don't tax the buildings, just the land.

New York is losing population at a breakneck pace. Our government is to blame.

I am for single payer to some extent, but if done poorly medical staff (who are already leaving due to pandemic policies) will just pick up and leave.

We recently expanded the privileges of nurse practitioners which is great, but two large nursing unions are less than 60 days away from striking.

Citation needed. Every population graph I can find show a small decline over the last few years but it's still above 2000 and they've had population dips before (1970-1980) that then recovered.

This comment reads like my in-laws who always talk about how "people can't get out of CA fast enough", um the population numbers say otherwise.

"A smaller Empire State: New York continues to lead nation in population decline"

https://www.democratandchronicle.com/story/news/politics/alb...

The population flight is primarily for US-born residents, which is what happened in CA as well.

One of the main errors that people miss is that the people leaving California and New York are the people making money and paying tax revenues.

Covid CRUSHED NYC tax revenues - and many people have still not returned.

From the article:

"Most of New York's population decline has been upstate."

CA is losing population: https://www.sfchronicle.com/bayarea/article/Bay-Area-countie... It isn't crazy fast but it is happening. We will see if the trend holds...

How much of this do you think comes from the Bay Area and Los Angeles housing costs and the ability to remote work in the last couple of years (which seems to be coming to an end... possibly) and how much do you think is because of policy and city deterioration which has been publicized?

I can't speak for CA but I see parallels in Seattle, though there's only movement to other cities within other WA cities (mainly the east side).

The common refrain is very Yogi-Berra-like, "nobody lives there anymore, it's too crowded."

Few people on the right want to connect things like rising homelessness -> rising rents and property values in the same period -> an influx of high paying jobs. There aren't concrete policy proposals given to fix those things given the circumstances of the last decade, just finger-pointing at whatever particularly policy someone doesn't like. The amount of gymnastics done to blame anything other than "importing a bunch of high-earners and/or wealthy people has unintended consequences" is high. E.g., pointing to pre-Covid out-migration overall numbers while ignoring net in-migration within the US for earners over 100K/yr. (I haven't seen if this has changed post-Covid, it wouldn't suprise me if it has, but one would want to keep an eye on it over the next two years as policies around WFH shift, of course.)

Why would you even mention "the right" in any conversation involving the governance of San Francisco? What level of control does a party need before accepting responsibility for their governing instead of looking for an exiled boogeyman to blame?

I’ve seen people argue that the lack of complete unity on CA politics is the cause of all problems; e.g. the right is still to blame.

Well, even CA still operates under the basic assumptions of contemporary US capitalism. There's a notable limit to what you can accomplish in terms of social change when you still cannot (or refuse to) directly control housing costs (for example), or control capital flows, or the labor share of (in this case, state) GDP.

While there are some great analyses that point out the flaws and hypocrisy in Democratic governance within CA, I think it's also equally true to say that the state's "left" leaning situation ends up pointing out the inherent contradictions of contemporary US capitalism as well as anything could.

I lived in SF for ~8 years and left during COVID and bought a house. I have worked remote for 5 years (long before covid). My quality of life is just better not living in SF. I should have left earlier. It is all of the reasons you listed and more.

Also, I am a startup junkie and avoiding CA's 13% capital gains has more than offset any pay cut I might take by working remote (which hasn't happened).

Our public school district in the south Bay Area had been steadily losing enrollment. I talked to one of the administrators and she said that based on student records transfer requests, the most common destination outside of California was Texas.

NY had been holding steady at about 6.5% of the US population since around 2010, but recently dipped just below 6%

https://united-states.reaproject.org/analysis/comparative-tr...

Doesn't sound like a "breakneck pace."

I don't see how expanding coverage will have any bearing on the quality of care givers. It's going to be the exact same doctors and nurses, just compensated from a different source.

> We recently expanded the privileges of nurse practitioners which is great, but two large nursing unions are less than 60 days away from striking.

The problem is that NPs are not fundamentally trained in diagnosis and have huge gaps in their medical training compared to physicians.

In the best case you go to an NP for a simple scrip. In the worst case you see a series of NPs and never get an accurate diagnosis, leading to a circular series of appointments.

NP = 2 year program on top of a 4 year nursing degree.

Physician = 1-3 years of fellowship (optional) + 3-7 years of residency + 4 year medical school on top of a 4 year bachelors degree

That's 60% marginal rates.

Last year I paid 17% of my total income in taxes.

You paid much more than that. A substantial part of your rent is property taxes. I also doubt you included sales taxes in that number. Then there's more esoteric stuff like tariffs, etc

Rent is not tax, what an absurd comment.

If you're renting, your landlord is paying property tax and passing it on to you.

Some states let you deduct a portion of rent in place of property tax.

By that logic, no one pays taxes except consumers.

I mean you’re sort of right. There’s no such thing as a free lunch. So stuff is all ultimately paid by the consumer since that’s the end of the line.

There’s really no way to increase taxes without impacting consumers. Unless you try to limit rents, but then you have other problems with people not wanting to invest in apartment buildings.

That assertion depends on an efficient market though, and that is provably not true - the existence of corporate profits demonstrates this, because in an efficient market everyone makes 0 profit, and any rent-seeking will cause every single one of your customers to flee to a competitor who doesn't rent-seek. Everyone has to price as aggressively as possible given the costs, or lose customers to someone who does, and that means zero profit above the actual cost of production/service.

In a world where corporations make profits, some competitors choose to eat the taxes and retain customers, while others may increase prices and lose some customers, and some customers may eat the increased price and remain even though they're getting a worse deal than before. This is the concept of "consumer surplus" vs "producer surplus", and taxes are cutting into those surpluses differently depending on the specifics of each market participant.

All of this has been debated endlessly by economists, in terms of just how much of corporate taxes get passed along to consumers and so on. And the answer seems to be "not zero, and not 100% either", and everything beyond that is up for debate. So no, not "everything is ultimately paid by the consumer", that is the 100% answer and that's pretty clearly wrong in a market where producer-surplus exists.

In reality, real-estate and rents are probably one of the least-efficient markets imaginable. The frictional costs to buying and selling property, and finding a new tenant who might be a problem/deadbeat/etc, or spending a bunch of time apartment-shopping, picking up your life and packing your stuff, and moving, are immense, and all parties involved are highly emotionally invested as well. Landlords are trying to make a long-term calculation about whether the property is going to appreciate - even if they are losing money today, if they expect to make capital gains in the long term it could be worth it. And all parties are operating with minimal information. Out of all the markets in the world, real-estate and rental living spaces are probably one of the least efficient possible.

Isn't this basically the case at the end of the day? Just about everything seems to eventually get passed on to the consumer.

Would you say my employer pays my income tax, since they're the ones giving me money?

Don't they, technically? Since the income tax is withheld from your paycheck before you get it?

One of many counter examples: Corporations holding investments with capital gains aren't sourcing tax payments from consumers.

Pass-through taxes exist though, yes.

Yes. Companies are legal fictions and all people buy goods and services. Some people buy those services through those legal fictions so they consume the fraction of them corresponding to their to ownership fraction. Ultimately a person pays all taxes and all people are consumers.

The point is, the apartment owner pays property tax and collect rent from tenants to pay for that. If property taxes go up, property owners raise rents to compensate. So the tenants are paying the property tax, albeit indirectly.

If the tenants will pay and it doesn't break any rules, why not raise rent before taxes go up and pocket the extra? (serious question)

This happens all the time. Deciding whether a raised rent price is justification for moving out is a complicated and personal process and yet it fuels all of the response to landlords that do this.

Also, 1-year leases are typical in the U.S. (at least Philly/NYC northeast U.S.), so from that contractual perspective, your rent can go up every year and that's totally legal.

If one landlord raises the rent, this will tend to make renters go to other landlords who are not raising the rent. But if the taxes are increased on all the landlords, they will likely all raise their rents together and renters can't simply go to another landlord who isn't raising the rent to avoid the increase.

Its actually much more complicated then that, depending on factors such as the propensity of landlords to cease renting out units if their profit decreases, the propensity of renters to shift to smaller dwellings in the face of rent increases, etc.

Landlords are also competing with each other and tenants have limits based on what they can actually afford to pay. At some point they can be forced to move out of the city to a lower cost of living location, dropping demand. In fact it's entirely possible for a significant increase in tax rates to make rental units a poor investment, causing housing prices to plummet and rents to drop.

Your mistake is assuming that people who bought up housing stock are guaranteed future profit on their speculative investment.

Step 1) Raise taxes on rental properties astronomically.

Step 2) Force out investor class and/or repossess properties out of tax adjudication.

Step 3) Public housing!

> In fact it's entirely possible for a significant increase in tax rates to make rental units a poor investment, causing housing prices to plummet and rents to drop.

How does this logic work? Building apartments becomes a bad investment. Then developers don't build apartments. And somehow constrained supply is supposed to result in lower prices?

What if developers built too many apartments so there is no shortage? What if the builders all decided to tear down the cheap apartments and build a bunch of Luxury Condominiums when the the housing market is full broke college students who can't even afford to cover the taxes on individual units?

You can say the market won't let it happen, but the second case is the current real estate market for the town I went to school in.

I’m a landlord and yes it is. My taxes doubled last year because of the stupid housing bubble and so we had to raise rent as well. Gotta make a profit here for this investment to be worthwhile.

Maybe if people didn't buy property they don't live in as an investment then things like the stupid housing bubble might not happen in the first place.

Personally I think owning a residence you don't actually live in should just straight up be illegal, but I'm admittedly pretty radical about parts of the system that seem to exist solely to make the rich richer.

If government reduced their hold on zoning restrictions and allowed for more properties to be built, we wouldn't be in this mess. Supply and demand.

I'm not sure of your logic.

There's no guarantee that builders will use the loosened restrictions to build the most efficient housing. In fact they will most likely build the most profitable housing instead.

The most profitable is on the high end - so marble countertops, stainless steel appliances, etc. All the builders will race to build as much of that as they can, as fast as they can. Then, when the market is glutted, they'll be unable to sell off their investments. Builders will end up with their capital all sunk in cheap land and expensive housing. no one can afford to buy. The builders can't sell the cheap land since they leveraged it to pay for developing the expensive housing. They can't sell the expensive housing because the market has temporarily dried up. The builders will just wait until the glut resolves and continue business as usual.

Meanwhile, there is not really that much more actual housing for the low end market. Some builders made a bunch of money and some craftsmen got extra work building houses they can never afford.

Capitalism at it's most typical.

> Then, when the market is glutted, they'll be unable to sell off their investments. Builders will end up with their capital all sunk in cheap land and expensive housing. no one can afford to buy. The builders can't sell the cheap land since they leveraged it to pay for developing the expensive housing. They can't sell the expensive housing because the market has temporarily dried up. The builders will just wait until the glut resolves and continue business as usual.

If there’s a glut in the market prices fall. If you have invested a lot of money in something in the hopes of selling it at a profit and you can’t you go out of business and your assets are sold. So if you over leverage and prices fall you go out of business and lose all your assets and the bank may lose some of its assets. Housing supply increases though. In a market where there’s excess demand at current price points (rising prices) that’s good.

Capitalism doesn’t make ever increasing housing prices, zoning does.

So, if I am going to live in an area for a year... I should be required to purchase a house, including all the money, time, and effort that involves? I would hate to live in a world where that was the case.

I have both owned and rented at different points in my life. There have been times where renting was a better choice for me, for a variety of reasons. I am glad that renting is an option.

In a world where there was no rentals there would probably be new things we can't imagine such as community ownerships. The specific thing that shouldn't exist - in parent commentors and myself is that the renter is paying money so that the actual owner pays off the property for their benefit, not the renter.

If some kind of community property system exists (not for ALL properties but a large number of them) then any rent you pay in say New York is also paying down a virtual mortgage you have the the "community" that spans the country. Like a virtual HOA.

That's how it used to work in the UK with social housing. The local authority would collect the rent and it would be used for upkeep of the properties, with surplus going to other public works. This was set up in the decades following the Second World War as Britain rebuilt, and it generally worked really well.

But then a right-wing government came to power and sold most of the social housing off, while banning local authorities from building any more. So now, we have the situation here where the large majority of tenants are renting from private landlords, who are just pocketing all the rent for themselves and doing the bare minimum upkeep, while holding a rapidly appreciating asset.

Which is exactly what the right-wingers wanted, but of course doesn't help everyone else who isn't a landlord, and just wants somewhere decent and affordable to live.

> Maybe if people didn't buy property they don't live in as an investment then things like the stupid housing bubble might not happen in the first place.

Sure would be awful for a rental market to exist. Without rental there’d be only be home owners and homeless and that is clearly a better world.

I respect the honest response. In my case, I'm not rich. I’m just trying to build up enough passive income to retire someday. There’s no pension for me. I can’t depend solely on my 401K. I’m just trying to be moderately responsible about my own future.

> My taxes doubled last year because of the stupid housing bubble and so we had to raise rent as well. Gotta make a profit here for this investment to be worthwhile

Surely you see stuff like this is part of what is driving this very bubble?

Yeah - that’s not lost on me. I didn’t even pass the full cost on. I’m still down. Just trying to hedge my losses at an acceptable rate.

You should've raised rent sooner. People clearly willing to pay.

Sell your building. Your taxes went up because your property value went up. You aren't entitled to a profit on rent. If you sell your building below what it's valued at, you'll still make a hefty profit, and it'll cause the value of other buildings to lower.

Land owners seem to feel entitled to businesses with no risk. Costs are always passed down, even if it makes people homeless. I'm more than happy with you going out of business if an event that makes you richer isn't an event that you can handle in terms of cost.

"rent" != "a substantial part of rent"

NY has low property taxes compared to most no-income-tax states

Where is that?

My parents lived in North County and paid 13k+ a year on a $350k house. Their current place in Tampa is about 400k and the taxes are less than half of what they were in NY. Maybe Florida is a special case?

WA is also lower than NY. I have a few properties, and I would say property tax is 0.75% to 1% of market value, max.

I'm basing this off of apartments in NYC. I often see ~$600k co-cops with $800 monthly co op fees (of which half is maintenance half is taxes). That seems low to me compared with similarly priced homes elsewhere.

NYC has has a city tax on your income. If you are living in the tristate area youre paying one way or the other :)

Property tax in New York City tends to be lowered because there is also an income tax. Try comparing homes outside the city.

NY's property taxes are among the highest in the nation (top 10).

Spot check, here's a ~1M apartment in NYC, vs a ~1M house in New Hampshire:

https://www.zillow.com/homedetails/41-W-72nd-St-APT-8C-New-Y...

https://www.zillow.com/homedetails/491-Marcy-St-Portsmouth-N...

Property taxes on the NYC place are estimated by Zillow at 715/month, while NH place is 1445/month. NH has no income tax.

NH is uniquely tilted towards real estate property taxes because it has no income and no broad sales tax.

So, I made a comment that it was in the top 10. Then you listed one that was dramatically higher. While I agree that NY doesn't compete for the top spot; your example in no way invalidates my point.

NY has insane property taxes. I pay 11k for a 400k house. I have not seen property taxes so high anywhere else in the country.

You can't just assume tax increases directly lead to increased 1:1 consumer prices, that's not how supply and demand works.

Where did I assume that?

- A substantial part of your rent is property taxes.

Without detailed analysis there's no way to know if this is true, or how true it is. It is entirely possible for an increase in taxes to lead to no increase in end prices or even a drop in rent prices. It's a complex system.

I didn't say anything about increases in taxes. You added that. I also didn't say anything about increases or drops in rent. You added that again.

All property taxes are paid from rents unless the landlord is operating at a loss.

Landlords are price takers. Supply is fixed short/medium run so just charge the maximum people will pay. Property tax rates have next to 0 effect on that.

>A substantial part of your rent is property taxes.

Here.

Without determining elasticity, it's impossible to determine how much of that cost is flowing through or how much goes to impact margin.

You're making a pretty fundamental mistake. I am not speculating about the elasticity of rent. If taxes went to 0, would rent go down? Probably not.

So what?

The percentage of rent that is taxes is exactly the amount paid in taxes by the landlord. Period. It is an absolute number.

But if property taxes go up you'd still be paying the same rent. I don't see how it makes sense to say you're paying property taxes when they have next to zero effect on your cost of living.

> I don't see how it makes sense to say you're paying property taxes when they have next to zero effect on your cost of living.

Why do they need to have an effect on rent for you to understand that you're paying them?

Bobby gave Lisa $10. Lisa then gave $3 to Uncle Sam. What percentage of Bobby's money went to Uncle Sam? 30%. It's that simple.

It’s not Bobby’s money that went to the government. It’s Lisa’s.

>You're making a pretty fundamental mistake

No I'm not. This is pretty entry level econ material. Price elasticity is very well studied and there's plenty of resources to learn more about it.

The renter is not paying the property taxes. The landlord is. This feels like a slight of hand that leads to double counting.

And what do you think rent price includes?

That's not how things work. When you file your taxes, your rental properties will be treated as a business and the taxes paid there are a business expense. They are deducted from any rental income before the income is counted for the landlord. It is essentially as if the renter is paying the government directly.

I'm entirely sure that landlord is not taking a loss on those property taxes. It is passed onto the renter.

No. Property tax rates are extremely- some would say criminally- low in NYC. I would think it unusual for more than 20% of rent to go to property tax.

Mortgage much much more likely to be the dominant expense for a residential landlord, but varies significantly with age.

There are many longtime landlords for whom their tenants are now nearly all profit. Which is INSANE.

Why are you assuming he lives in NYC?

Because they are responding to the OP (who is talking about NYC) and further elaborating on NYC taxes, while describing their (supposed) NYC tax burden.

OP didn’t say anything about NYC?

And don’t forget your healthcare costs.

"To some economists, the question is moot: Americans already pay a massive “tax” to fund health care, they say. It just happens to go to private insurance companies, rather than the federal government."

...

"Health insurance costs raise the average effective tax rate on American labor from 29 percent to 37 percent, they said."

https://www.washingtonpost.com/business/2019/10/16/americans...

Prices are determined by supply and demand. Both are rather inelastic, especially in a highly desirable city like NYC, so very of the property taxes gets passed to the renters. If this weren't true, then renters in California would see savings from prop 13, but clearly that isn't happening.

Bobby gave Lisa $10. Lisa then gave $3 to Uncle Sam. What percentage of Bobby's money went to Uncle Sam? 30%. It's that simple. Bobby gave Uncle Sam 30% of his money.

If you use that logic, 100% of Bobby's money goes to Uncle Sam after a long enough chain of transactions.

We can stop at 3rd parties. That's reasonable enough.

> Last year I paid 17% of my total income in taxes.

Was that in NYS? It doesn't take a lot of income to hit the state rate of 6.33%, everything after $80,651 filing alone, which isn't unusual downstate. You can add roughly 3.8% to that if you live in NYC and another 22% Federally, all just on income.

I don't want to be rude, but if you paid 17%, that's basically the minimum income tax rate (10+4+3) for NYC. That's pretty far form the OP's "NYC high earners". Of course, if you got credits, that's orthogonal as normally those credits cost more than they are worth. For instance, the child credit is far from the cast of raising a child.

If you're a "high earner" there are a panoply of services that allow you to structure your income, wealth appreciation, or other forms of wealth generation in tax-optimized vehicles.

The tax universes at 200k/yr and 500k/yr-2m/yr income look very different.

If we're talking wages here, what are the options exactly? Is there anything bigger than 401(k)?

This is ignoring charity, which I believe is available to anyone anyway.

I believe - someone more financially literate (and far richer!) correct me if I'm wrong - that you can convert some of those wages into various different vehicles and get paid in non-wage forms in certain cases. Correlation != causation of course, but if you're making $500k/year chances are pretty good a large chunk of that is non-wage income such as capital gains, corporate bonuses, trust funds, etc. And even if it was all wage-derived, over time you could easily realize major capital gains on it if you're lucky enough to (a) make a huge chunk 'o change, (b) have low-enough cost of living to be able to move it into investments and then (c) have enough life stability to be able to continue this pattern for several years or decades (or better yet, have grandparents and parents who did then passed the wealth down to you). Even after taxes as high as 50%, with enough raw wage income you can definitely pivot your "margin" into vehicles that yield serious ROI over time, and can even leverage the highly disparate cost of living to your advantage: use NYC's housing market to justify a ridiculous salary, then live super cheap out there somehow (insert hand-waving magic reference here), and use the difference to buy housing out in, say, rural Texas or Kansas before the pandemic, rent it out via property company, reap profit month-after-month.

From there you follow the directions on your shampoo bottle:

1. Lather

2. Rinse

3. Repeat

I am not an accountant nor someone who benefits from these deductions, but I'm casually interested. From what I've seen, a few: 1. Charity can be meaningfully different from chipping in $200 to something if you can afford to pay for large parts of a program, meaning things can have your name on them, or you can get events that you care about hosted at your church while saving on your taxes. 2. Tax advantaged accounts everywhere. Max out all retirement of course, but also education accounts for your four kids. Then I think there's some interesting tax advantages to whole life insurance, but I don't know which end those come on. 3. Structuring more of your life as a business. For example, I use my affordable car almost exclusively for work but it's not worth the trouble to track it for deductions because I still do best with standard deduction. Once you pass that, may as well track everything. And you should buy a large SUV instead of a minivan for your family so you can use the more favorable depreciation schedule that encourages SUV use over minivan and car use. Deduct your laptop and phone and phone plan because if you're making a lot of money, there's almost no chance you're using those for personal stuff more than for business. Probably some travel and dining fit as deductions too. Clothing, maybe? This is all completely legitimate (well, maybe it's not because of my ignorance on particular applications, but the spirit is consistent with how deductions work.)

You also may have the ability to structure some of your income as business appreciation so as to not pay taxes yet. True, it's still trapped until you pay taxes, but it's still resources you have available to you that haven't yet caused you to suffer tax expenditures. As a rule, you should never volunteer taxes that you can legally defer.

It'll all add up, though probably not to an overwhelming amount. My impression is that a lot of the exaggerations of low tax rates come from very slimy accounting driven by agendas (to say nothing of expressing taxes in a given year as a fraction of total accumulated wealth.)

> For example, I use my affordable car almost exclusively for work but it's not worth the trouble to track it for deductions because I still do best with standard deduction

That's not how business expenses work. Talk to an accountant, you're leaving money on the table.

401k, HSA, 529s for state taxes. You can give children gifts up to $28k, which is taxed at the kids rate. There are games you can play with home equity loans.

If you own a business there is a thousand ways to do it. One thing I’ve seen is people’s businesses “donate” to private schools and then get “merit” scholarships for their kids. You can accelerate depreciation of up to $500k of assets, etc.

If you’re smart, you’ll sometimes pay less tax in high tax states. Usually the low tax states have higher property and sales tax rates.

Re: 529s, do remember that tax treatment varies widely state to state. I was bummed to learn that California doesn't offer any deductions for 529 contributions.

(Of course the tax treatment for qualified withdrawals is the same regardless of where you live.)

A number of the comments to your post have some vague sense of what's going on.

The key concept is that as you get more wealthy, you will have access to professionals and tax structures that allow you to defer and recharacterize significant portions of your revenue streams into tax advantaged forms. The exact mechanisms change depending on jurisdiction and asset mix.

Advisory services take money to purchase, but their cost, and the cost of various vehicles used to avoid taxes, do not scale linearly with the amount of wealth to shelter.

The panama and various other financial leak disclosure reporting provide a decently accessible area for lay-persons to investigate. If you'd like to see the effects of scale - there's a lot of literature regarding the multi-national corporation side of tax avoidance in academic journals that's easily found via google scholar or sci-hub.

If you’re earning 500k-2m from your own business/investments, this might be true.

If you’re earning that as w2 income (as many of the nyc high earner taxpayers are), then yeah you’re gonna be paying >50% taxes if you live in nyc.

Speaking from my own experience.

If you own your home and are married the rate comes down until you make >500.

I live in NY, not NYC and pay ~18%, or ~22% with property tax.

I can't think of what county you must live in where you'd be able to afford a home in NYS and pay that little in fed+state+local without any special deductions.

There are 57 of them. :)

Probably depends what you mean by high income. I think someone making 100k will not pay that much and that is considered high in a lot of places. But I am not sure that is considered high in NYC. High is probably more like 150k - 200k+ and that still wont be anywhere near 60%.

I do get to ~40% when you add up federal, state and city. I don't think anyone is really looking at an actual 60%. Maybe 50% if you're making like over a million.

Median household income in NYC for 2020 was $67k [0]. $100k (especially for a single earner, as is often the case in tech) is considered quite high, but not outrageously so if that makes sense? That's "1BR apartment in a nice but not too trendy neighborhood outside of Manhattan" money, so well on the upper side of middle class. I think people tend to overestimate how much money those outside of the tech bubble actually make.

[0] https://www.census.gov/quickfacts/fact/table/newyorkcitynewy...

I’m in Quebec so I paid 29% on everything over 66k to federal and my provincial rates were 20% (over 50k), 26% (over 100k), and 29% (over 150k).

We also have a 15% sales tax. I paid more than a 50% effective rate last year. This is the cost of our social safety net. It feels like too much too me and I’ll be relocating next year.

Quebec has one of the higher tax rates in canada. You still get a similar safety net in the rest of canada for lower (albeit still high if you are a high earner) taxes.

yeah here in NZ we pay 39% marginal over $180k, 33% $70k-180k - no state tax - mostly free public health (5$/drug $100 max per year, $30 to visit GP, nothing for hospital/urgent care/everything else)

What we don't do is spen d all our money on a military industrial complex

> What we don't do is spen d all our money on a military industrial complex

I know it's a bit of a meme, but military spending is far from our only problem. We could cut military spending to $0 and not even make a dent in the defecit, let alone be able to cut taxes. Social security, Medicare, and medicaid together make up 42% of federal spending. (Not to mention food assistance, housing assistance, unemployment, or the dozens of other programs). The US spends a lot on social programs! We just don't get much of anything for it.

EDIT: for completeness - defense spending was 12% of the federal budget in 2021.

[1] https://www.thebalance.com/u-s-federal-budget-breakdown-3305...

last year we spent 25% on social welfare (everything from retirement pensions to the dole), 17% on healthcare for all, 13% on education (from preschool to tertiary) - military was ~3%

One big difference of course is that here in NZ the govt owns the hospitals and doesn't run them for profit, no one takes a cut providing insurance either. We bulk buy pharma for the entire country. We also have a no-fault accident insurance scheme that takes personal injury out of the courts (fewer courts, fewer lawyers, smaller law schools in universities)

Yes, for sure. I’m not sure what causes Quebec to be so much higher. Our health care system has struggled immensely with the pandemic even with so much funding.

We may have a stronger government programs than most (subsidized parental leave, subsided childcare, subsidized French language media, etc), but almost none of them give any benefit to me.

Part of the difficulty to me is our high rates seem to kick in very early. A lot of other regions also have very high top tax brackets, but very few places are starting their top tax brackets at 100k/y income.

I don't think the op is talking about you. Many professionals in NYC already pay over 40% in effective income tax.

I paid 38% of my total income in taxes in New York City.

How do you manage that? I get 31% taken straight from my paycheck (state + federal income, socsec, medicare, etc, and this is after 401k deduction) and then have sales tax and property tax on top.

If you’re earning 1m + in w2 income, then your effective rate is right about 50% in nyc. If the marginal tax bracket goes to 60%, high earners will definitely be moving. Nyc really has a high opinion of itself if they think people are going to be willing to pay 20% extra in taxes for the privilege of living in a city where garbage is left on the sidewalks and infrastructure is constantly breaking down

In NYC?

One of America's best ideas. Laboratories of democracy. Maybe it works.. maybe not. But the rest of us learn from whatever happens.

NY currently greatly restricts how health insurers can discriminate on price based on age to the point that age basically isn't a factor. But most states allow for a ~3x price difference based on age. The other state with a similar rule, Vermont, has a form of single payer insurance as well

It's the federal Affordable Care Act (Obamacare) that limits price discrimination based on age to 3×. A few states do compress that even further.

https://www.valuepenguin.com/how-age-affects-health-insuranc...

"Single payer" is just another word for Monopoly. It's insane anyone thinks this is a good idea. Just Google "quebec/canada healthcare crisis"

4 states would be about 1/3 of all of USA's population too...

Isn’t this sort of guaranteed to fail? High earners already have great insurance from employers. There’s not likely to be a mechanism to get those benefits back as dollars like you would expect in a national scale steady state system.

The VOX in the weeds healthcare people looked at it some time ago, and most healthcare economists thinks it is not possible for states to do something here.

Somehow they have private insurance in Europe too. Germany has universal health care and you are well advised to get private insurance if you make enough that the state will allow you to buy it. The threshold is a salary of about $68K/year in US dollars.

That’s not what I’m saying. The norm is that a fairly substantial part of your comp in the US is healthcare provided by your employer. If this suddenly becomes worthless (or rather much less valuable because there’s a single payer system in parallel) but your salary stays the same while your taxes go up, you will lose out big time.

It could work just fine if everyone did it. But seems very hard to do just Ny.

The notional value of insurance isn't impossibly high and it would likely loosen up the job market if switching was not complicated by continuing coverage and the risk of not replacing a good benefit.

Sure. But is that achievable over a short period when the experiment is New York only and you’re a large national company? Not convinced.

Having used VA healthcare, what data do you have to show that the gov provided medical services will be a “good benefit”?

I have some medical issues now due to those wonderful Drs decisions.

This came up in the VOX in the weeds on healthcare policy some time ago. Their conclusion from the people that had looked into it is that it is sort of impossible for states to do this. Can't really remember the reasons.

There was another state that was trying something like this, I believe it was Vermont.

I'm guessing the economy of scale for such a buy in isn't enough, and that states would have to take out as much debt as their yearly budgets or even more. Even a Elizabeth Warren's proposed solution was something like 17x the federal budget.

States wouldn't be able to borrow on anything like that scale to fund a healthcare program. Any major increases in healthcare spending would have to be funded by huge tax increases.

> increases in healthcare spending

FWIW, New York's current Medicaid budget alone puts it between San Marino and Israel for per capita healthcare spending. Widening the net a bit, that's between Italy and the UK.

NYS has a bigger population than all of Canada which seems to do make universal healthcare work.

There’s comments above that explains it “working”. Here’s a site that explains it better. TLDR, taxes go up a lot, private spending for medical procedures slightly falls. Quality of care drops. Pretty well a losing proposition all the way around.

https://www.heritage.org/health-care-reform/report/how-socia...

> Their conclusion from the people that had looked into it is that it is sort of impossible for states to do this. Can't really remember the reasons.

adverse selection is the usual objection raised. If you can live in Montana while you're healthy, and move to New York when you're sick, then New York effectively becomes the dumping ground for the nation's sick and ends up picking up a hugely disproportionate amount of the tab without the revenue base to make it up.

That said, since coastal states make up a disproportionate amount of the economic activity anyway... they may be able to power through it, especially if they can all get onboard with it at the same time. It's not like de-facto cash transfers to the poorer "heartland" states are a new thing in the US.

People don’t move for various reasons, and now sick people are going to move for healthcare?

It’s not financially possible. The tax rate will be so high healthy people will then leave and you’ll be left with a fat bill for your sick population.

You have it backwards, you won’t get more sick people you’ll have less healthy people covering the bills.

The inability to run deficits is the killer here.

Where does 60% come from?

I used this calculator - https://smartasset.com/taxes/income-taxes

It said if I (married) made $675,745/year in Manhattan I'd pay 39.59% of my income in taxes.

im adding marginal rates which is somewhat lazy. assuming 1,080,000 as a single earner (married changes the calculation of course):

  - 37% federal
  - 9.65% state
  - 3.876% city tax
  - 3% SS and medicare
  - ?? disability, unemployment, etc.
  - some additional % to cover single payer

so thats somewhere in the mid 50% range adding up. again, effective rates won't be that exact number except for ultra high earners. this also doesn't include property tax or sales tax (8.875%).

crocodile tears for million dollar earners and their tax bills of course, my point being that chasing away a small amount of residents can have an outsized effect on state revenue. (0.3% of returns account for 27% of revenue federally)

This is how it worked in canada.

Saskatchewan decided they wanted single payer health care so they did it. About a decade later the federal gov made it national.

...and why combined tax rates for the middle class are around 50%.

As someone who's lived in the Canadian health care system and the US system - it is absolutely lower quality than what average private employer healthcare plan provides in the US.

Even before covid, Quebec's healthcare system was in crisis with packed ERs having dozens of neglected patients on beds in the hallways for weeks... GP access is impossible with waiting lists 3 years long. ...and the nursing shortage was bad before - now because covid caused the government to order nurses to do forced overtime.

Americans have rose-colored glasses when they think about the quality of care in Canada. The truth is that Canadian healthcare is better for people that cannot afford healthcare. ...and American healthcare is far better for the average person that is employed with those benefits.

It's a simple tradeoff. Significantly higher taxes + healthcare for the poor (Canada) vs better healthcare for the average middle-class employed person (US).

The US already spends more than double what Canada spends per capita. If we had the cost efficiency of Canada's health care system, we could by double the health care without spending more than we already do.

The US spends more because our care is higher quality. If you want to see a specialist for instance, the top of their fields will be here because they can charge what they’re worth.

> ...and why combined tax rates for the middle class are around 50%.

I think you are confusing middle class and 1%.

Stats canada says middle class is $45,000 to $120,000. That is a marginal tax rate of about 30% depending on what province and where in that range you fall (quebec is closer to 40%). https://www.mackenzieinvestments.com/en/services/tax-and-est...

> NYC high earners are going to be knocking on the door of 60% combined rates (city, state, federal). tax avoidance and/or relocation services are going to be booming if so.

It turns out that people don't often move over taxes, despite the claims of the anti-tax crowd, or NY and CA would have been emptied out long ago. Taxes are investment; we need to start calling them 'low-investment' and 'high-investment' states (but the liberal crowd is blind to the power of messaging and perception). People like the services and the community that investment creates, such a health care and arts.

Also, they can subtract their health insurance costs, and you are only talking about income taxes, while most taxes are either fixed rate for benefits (e.g., Social Security) or, for the wealthy, capital gains.

This is anecdotal, but I know multiple people who have moved to Washington and Texas from NY and CA specifically to save on taxes from large stock grants at tech companies. I don’t think this is a unique experience in the tech industry. At a large public company I worked for, an entire team ended up moving.

I don't know those people and of course can't judge anyone else but me. Generally, the trendy focus on taxes is absurdity. They are making all that money, and are uprooting their lives and family, not to mention the other benefits of living in world cultural and technology capital (which isn't coincidental to the taxes and resulting community investment), to save on taxes? I hope they see that some things are more important in life.

Seattle and Austin are totally comparable, even preferable, to NYC and SF in many ways. So yes, all else equal, why not save an extra 10% of your income?

> Seattle and Austin are totally comparable, even preferable, to NYC and SF in many ways.

I'm sure we can find ways, Seattle and Austin are wonderful places, and what makes NYC and SF special doesn't appeal to everyone. But really Seattle and Austin are not even close. There's a reason NYC and SF have been centers of culture and business for generations; there's a reason that demand is so high that housing costs are stratospheric.

Sure NYC has certain desirable aspects. Seattle has a different set (e.g. way better nature). The point isn’t to compare the cities to find the absolute best. Rather, the question is whether or not the benefits of certain cities or worth the cost. For high earners, the cost of living in NYC is hundreds of thousands or even millions of dollars per year. For some percentage of people that cost is simply not worth it and they move. To claim people don’t move because of taxes is to deny basic economics.

> To claim people don’t move because of taxes is to deny basic economics.

No, it's just not framing the entire economic question around taxes. There are many, many other factors. You can live in places with no taxes at all, but people don't choose to.

> the cost of living in NYC is hundreds of thousands or even millions of dollars per year. For some percentage of people that cost is simply not worth it and they move

They've already moved in that case, but the demand for NYC is enormous.

> For high earners,

Who do you think lives in NYC?

Maybe we're discussing different things. I was responding to the claim that higher taxes doesn't cause people to move. Just because high earners live in NYC doesn't mean that there weren't some high earners that left due to taxes.

I think if states become more heterogenous (and SCOTUS seems to be on that wavelength) the idea is "if you don't like the new laws, relocate". Which sounds great; more diversity of laws, more states that are likely to fit my values more closely.

But this impacts poor people disproportionately. If you're poor it'll be hard or impossible to relocate.

It also impacts people who consider themselves something other than "rootless cosmopolitans".

I do happen to proudly put myself in the rootless cosmopolitan category, but I've had some interesting interactions (even here on HN) with people for whom community, place, family ties, family history etc. are much more important than they are to someone like me. "Relocate" is a particularly jarring edict for such folk.

I agree. I currently live in a small city where locals take a lot of pride in their families having been here for generations.

if you live in NYC as a high earner, you already have some of the highest tax rates in the country. A lot of people who are high earners in NYC make their money through w2 income, so there's no way to avoid paying ~50% in taxes.

Anecdotally, I know so many people in this >1M "high earning" bracket who have moved out of NYC to Austin/Miami/Tampa/Seattle in the last couple of years. Especially now that remote work is a viable choice at many companies. Every year you're saving somewhere between 8-10% in taxes, which is upwards of 100k/year.

Whatever your stance on higher taxes for the wealthy are, as long as viable alternative locations exist in the USA where there is such a massive discrepancy in the taxes, you're not going to be able to raise more revenue in NYS/NYC by simply raising the marginal tax rate for the highest earners.

If they actually increased taxes to fund this, I highly doubt they will be able to raise additional revenue, and the primary effect will be driving up home prices even further in the tax-free cities above

Yeah. If a European country who is poorer than NY with a population of 20 million can fund universal healthcare, NY should be able to also.

European countries ration care. America does not. Until we're willing to, health care costs will remain astronomical.

Coming from a country that has this, there should be caution: it gets more affordable, but you get what you pay for. In my country of origin, you get a partially-paid-for ride to the emergency room, where you pay for things like casts, non-ward rooms, dental care out of pocket. There is no prescription coverage. There is no optometry coverage. I would wait significant chunks of a year for procedures and diagnostics. To cover the things that aren't covered, most have private insurance through work or also out of pocket.

Since moving to the US, it is more expensive (than next to nothing), but I actually get good care. Several conditions that were ignored or misdiagnosed for me are now cured. My life might be significantly shorter had I not come here.

If NY does this, the near zero chance of my moving there ever would go to absolute 0. It is a terrible system for any place that does not have infinitesimal state or national government expenses and more-than-60% kind of taxes (e.g., Scandinavian countries).

Interesting, from where do you hail?

>> but you get what you pay for.

Americans are already paying more than most places for healthcare but not getting a good return.

Is this true even for individuals? I think one version of the problem might be that we pay too little for some peoples healthcare and too much for others, but do the people who pay the most still end up with worse results?

The same procedure costs magnitudes more in the USA. It is true for everybody.

An adjacent issue is that certain groups don't receive preventive care due to financial issues leading to increased long term costs.

But note, even in all cases we're paying way too much.

Who gets "good" care here? Senators and millionaires definitely do. But, most people don't get good care, many people are missing essential care (dental), and everyone has to wait. Often months.

We in the US pay more per capita for worse care than most other developed nations (Canada/UK/Nordic countries). Name your country where the care is worse than the US please and let us know how much they pay for it per capita comparatively.

You ever been to a Canadian hospital?

I have Canadian friends and it sounds better than when my older brother had to call their insurance company every months to get their anxiety meds covered because, for some reason, the insurance company lost the paper work for approving them every month. For a year.

Funny because it’s just the sort of thing to cause more anxiety in an anxious person.

I’d also love hear how many Canadian cancer survivors have to put up gofundmes or go bankrupt for care.

https://www.cbc.ca/amp/1.4495123

Who here is saying Canadians are perfect? I’m sure it’s easy to find individuals who had a better experience in the US.

> You ever been to a Canadian hospital?

As a Canadian: yes.

And the bill was $0 at the end of my father's heart bypass and valve replacement surgery. My friend's sister cancer treatment also had a bill of $0.

Finished filing my taxes last month, and my average rate (provincial+federal) for last year was 21%. Happy to pay.

https://www.cbc.ca/amp/1.4495123

“ "Then I found out that this other country — which I thought had a healthcare system that was so superior to the U.S. — doesn't test for the tumour marker that saved my life, and doesn't cover this drug that is responsible for pushing my cancer into remission after traditional chemotherapy failed to do that."”

"... and then I found out that this other country - which I thought had the best healthcare system in the world - allowed for-profit insurance companies to dictate what treatment would be paid for, and allowed millions of people without insurance to likely go without any sort of test for cancer at all."

I'm not sure I'd feel better with the explanation "No, we won't pay to cure your cancer, but hey, if you were in the US there is a chance they won't pay for it either!"

Pretty sure I'd prefer even a 5% chance versus a guaranteed 0%.

Not to mention the fact that the entire argument is a strawman. US insurance companies almost always fold in the end.

Folding doesn't help someone with a US$7000 deductible but no means to pay it.

Legit every major drug company would give you the drug in question for free, not to mention Medicaid, which if you can't afford 7k, you would easily qualify for.

Have you? Do tell.

I've been to multiple Canadian ERs (2 times total) and multiple US ERs (2 times total).

The only difference has been that 1 time the Canadian ER was busier and I waited my turn (based on an initial triage).

I feel, during my visit, I was appropriately handled in all 4 locations. After leaving the hospital in Canada I was done. However in the US, both times a few weeks later I got a bill for roughly $1000, and it actively makes me think twice about going to the ER (even though I can afford the $1000). In the US, I may have skipped the ER the second time if I hadn't felt strongly I was having an appendicitis. Truly scary to think I considered not going based on a bit of money.

If it wasn't clear, even being well off in the US, I prefer the overall experience in Canada.

I have, as have members of my family, and have received excellent care for some fairly serious conditions. I think the Canadian system is under funded, and I'm sure there are plenty of true horror stories, but they always get highlighted by people who want to tear down/prevent a public healcare system so I feel I have to bring up that my family have received good and timely care. When I really needed healthcare I was unemployed and it was stressful enough seeking care without having to worry about insurance. Now that I'm employed I'm happy to pay back into the system.

I value having public health care. I hope the US can come up with a good public system so that Canada can stop resting on "at least we're not like the US!"

It really seems to be one of those things where depending on who you are, you are better off under one system or the other. I have an aunt who was handicap from birth. Her care in Canada from birth to her death in her 70s was far better than what she would have received in the US under Medicaid, which is what her disability likely would have restricted her to as her ability to work and access quality health insurance would have been limited. On the other hand, there's no shortage of Canadians who end up coming over to the US to get timely care that the Canadian system treats as low priority even though it has a large quality of life impact and even in some cases, a life expectancy impact. There was a case recently of a Canadian YouTuber living in Japan who ended up in Florida for treatment because both the Japanese and Canadian systems failed her. The comparisons between systems aren't anywhere near as clear as many would have us believe.

Those stories aren’t irreconcilable. The US is huge and has a lot of specialists and I don’t doubt there are some cases where you can get better treatment in the US, especially if you’re rich.

The issue is we fail most people and those we don’t fail we often bankrupt. That isn’t acceptable.

Yeah, I've also had friends and family go. No complaints.

Why do you ask?

The quality of Canadian healthcare depends greatly on who is in the room having the discussion about it. If it's just my Canadian relatives discussing it, it's the worst healthcare system on Earth and too much of their taxes goes to funding something to provides garbage care. Once someone from the US enters the conversation, the quality of the Canadian healthcare system skyrockets. Things get really interesting when my cousins from Ontario who have lived in Florida for most of their adult lives get in the conversation since they're willing to call out both sides on their BS.

Actually, the median American has access to exceptional care.

What is actually the case is that care available to the bottom quartile of Americans is below the care received on average in a top-tier universal care nation, and the US spends an absolute fortune delivering this quartile with substandard care.

We also spend a bit more than average providing exceptional care to everyone else, except that we also spend a truly ludicrous amount (compared with every place on earth except possibly Japan, which is still less than us but not quite as much less) on care for roughly everybody above the median during the last year of life, because we have baked some very expensive decisions in as the default (basically, if you don't specifically ask otherwise, you will get absolute treatment maximalism basically until 30 days from death)

Why do Americans always have to play a zero sum game with human lives.

If a quarter of our country has the worst healthcare in the developed world that is unacceptable.

Answers like this are just begging us to give up our humanity.

I have made no statements about how things should be. I have lots of opinions about how things should be, which I don't share on HN.

I was making statements about how things actually are, since no discussion about how to make the world we want is likely to be meaningful or useful if there is not a shared view of what is first.

And what you focus on brings about thoughts of a zero sum game which I called out. You can safely assume I don’t agree with what you find most pertinent.

I think a country which lets some get rich off of other’s cancer is an abhorrent, indefensible, system.

I'm not seeing that out of his comment. I see him saying we spend a ton of money, and there's the implication that we could be spending that money better/differently. That doesn't imply a zero-sum game. It does imply that the money available for health care is not unlimited. That's pretty much a fact, though.

How do you incentivize smart people to go into cancer treatment instead of other careers? If they can't get rich treating cancer, talent will choose other fields where they can get rich. The market allocates funding to that which people find important. Health care is extremely important, so it gets a lot money thrown at it.

Countries other than the US exist. Doctors, health care workers etc are significantly less paid in Japan and yet they still exist.

The idea of 'market forces dictating absolutely everything' is proven objectively wrong by countries that still have a large amount of doctors despite being paid less. The market theory would posit that all of those doctors and what not would move to a country that pays them more but there are many, many other factors other than just pay.

> I think a country which lets some get rich off of other’s cancer is an abhorrent, indefensible, system.

lol

You are assuming that I believe many things which I do not.

You should just assume I'm a misanthrope who enjoys watching people suffer. I mean, it's not true, but lots of idiots assume it.

What fraction of your income goes to the third world?

> Actually, the median American has access to exceptional care.

Is there a source for this? I'd guess that there's a percentile where American health care has better outcomes than other countries, but 50th seems pretty low.

60% of the US has access to "good" healthcare. Why is it ok to throw the under 40% under the bus?

Why is it ok to force the 60% to pay higher taxes and accept WORSE healthcare so that the 40% get better healtcare for nothing?

We already pay to cover our own family members on our plans. Why are we being forced to now cover everyone else's family?

I'm more likely to move to the adjacent state than pay 15% higher tax rate and literally get LOWER quality care.

1) It's not clear it will be worse, many countries with single insurer/single payer have just as high quality care (Canada)

2) Leaving these people uninsured is not cheaper, you're paying for it already with significant healthcare costs. The same people complaining about the cost of healthcare turn around and deny preventative coverage to people who end up in the ER and you pay for it regardless.

3) It's the right thing to do, ethically, morally and financially (long term)

What an incredibly ignorant take, no wonder we don't have any healthcare solutions.

My wife, a practicing surgeon, refuses to work as a wage slave.

She already performs a significant amount of her practice as "charity care" where she gets no reimbursement whatsoever.

Given that for a fellowship-trained (3) board-certified (2) surgeon the train-up period is measured in ~2+ decades, not 4 years for regular professions.

> What an incredibly ignorant take, no wonder we don't have any healthcare solutions

Please don't assign false morality to the compensation people expect when their working career is effectively halved due to their extensive training requirements, and their educational bills dwarf by comparison every other profession.

The US already subsidizes medical research and bigpharma profits for the entire planet. We're not the freeloaders you're making us out to be.

Are you from Canada, or was that just an uncanny description of Canadian healthcare?

For your first paragraph, I’ve seen that alot.

My european friends from big economies there brag about their insurance coverage, some working in the states with some global coverage plan, and as soon as I ask about something seemingly basic: “oh thats elective or cosmetic, why would that be covered”

I think there is a way to make it work with American expectations, American resources, no equivalent tax burden.

> and as soon as I ask about something seemingly basic

Do you have an example?

Two points:

1) In the USA, one must be pretty well situated to get the quality of healthcare you describe. MANY people go without prescriptions, and get inadequate care already.

2) If you add up what we pay in health insurance premiums plus employer contributions, especially if you have a family, we're generally in the same league of paycheck-subtraction as a European country with universal healthcare.

So while I agree with your overall point that it could end up worse than where we started, I don't think thats a guaranteed outcome.

Would healthcare overall in e.g New York be equivalent though? In Canada, we have "free" healthcare but literally have no other option so it's the Soviet style mess you'd expect a government monopoly to be. But would this bar paid healthcare? Couldn't people still have health insurance and get private care? Is there something preventing that?

This bill doesn't ban private insurance, it does however have this rule:

"Private insurance that duplicates benefits offered under New York Health could not be offered to New York residents."

So in other words, private insurances can only be offered if they provide benefits that surpass whatever the public option has.

I imagine that private insurances will logically offer more benefits regardless, otherwise why would someone pay extra to use them over the public option?

that will mean, though, that it will be impossible to get insurance to actually cover the things that the public system "covers" if you wait 35,600 years for your turn

Why? Wouldn't a line skip be by definition something that the public system isn't offering?

I haven't read the full text of the bill, but presumably not. The intent will be to disallow private coverage for any service that the government would provide, specifically because they would want to make sure that people with money couldn't avoid the public system.

That's how it ends up working in many places with government care

I don't know of any healthcare system where what you're describing is the case outside of outliers like North Korea. Even in the UK with NHS, there's a whole system of private insurance and private hospitals too.

In Norway and UK there is public healthcare, but you can pay to skip the lines if you want to. I don't know why we would go full socialist in the US when living in a capitalist society. Should we only get cars allocated to us or something as well?

I am not hugely in favor or capitalism, but I can't see anything better or a way to replace it even though I am a social democrat. Let people with money spend them as long as we provide a decent floor for everyone.

I went to a clinic in Canada a few years ago to see a doctor. My provincial health card had expired and I didn't know. I was sick and wanted a consultation with the doctor. I said I would pay cash and was told that they are not allowed to charge people who are eligible for public healthcare. So I had to go and wait at our equivalent of the DMV (while sick and seeking medical attention) to get my health card renewed before I could see a doctor. I'm sure there are countless bureaucratic nightmare stories coming out of the US health insurance system, there will be countless more under a public system

Don't know why you were modded down (well I do but I don't want to start a fight), this is exactly how it works in Canada. I know people who have been told to wait years for tests or consultations. Those who can afford it go to the US.

Yes, it is very common, but HN is one of those places where one is required to have the community's approved opinions on things, and even the approved supposed-facts on things.

Of course many systems, including Canada's have this problem. The primary motivation for governments to prohibit private competition is specifically so that they can pretend that it can't be better elsewhere, to keep their system alive.

If people realized how likely they were to suffer for years utterly unnecessarily, they wouldn't be willing to put up with the government health systems they have. But because the government banned competition to keep them ignorant of the alternative, people remain peaceful while they wait in pain for years to get treatment that is utterly routine in America.

You realize the only reason rich Americans don’t wait for healthcare is because poor Americans aren’t getting much if any care.

This shows a serious misunderstanding of pretty much everything (I mean that).

It's not a zero sum game.

Where will the additional doctors and MRI machines come from if more folks had access to healthcare? If all the uninsured in my state suddenly had the same access to health care as I did, there would be 700,000 additional people who need primary care physicians, OBGYNs, psychiatrists, and so on. I think it would be a net good, but I would absolutely expect that the wait time for treatment would go up. You can't just snap doctors into existence. (I mean that)

Healthcare in the US isn't fair for anyone.

I’m a Canadian living and working in the US and I’d take the Canadian system any day of the week.

I think it’s crazy that your access to healthcare is dependent on your employment.

But it's also crazy that your access to healthcare is based on how the government prioritizes your need of it.

I agree with the idea of public healthcare, but not as a legislated monopoly. And that's true for government services generally. Monopolies don't benefit anyone except the monopolist, and competition makes everyone stronger. If the government wants to use it's buying and borrowing power (and maybe even taxation to the extent voters tolerate it) to provide a universal healthcare option, that's a big win. But if they want to push out other market participants in the name of some kind of fairness - well instead of having two-tier healthcare, everyone is on the bottom tier

> But it's also crazy that your access to healthcare is based on how the government prioritizes your need of it.

Triage is a pretty universal concept.

Healthcare has difficulty with competitive market effects because the amount anyone is willing to pay to live is essentially infinite.

>"... the amount anyone will pay to live is essentially infinite."

This has actually been studied, and is not true.

I suspect that there are people who would rather die than burden their families with crushing debt but that's a slightly different issue.

> But it's also crazy that your access to healthcare is based on how the government prioritizes your need of it.

So does every private insurer under the sun. You've never had insurance deny access to care? No insurer can afford to give an MRI to everyone a doctor wants.

> But it's also crazy that your access to healthcare is based on how the government prioritizes your need of it.

Doctor's prioritize need. More sicker, more quicker 'service' / treatment.

> I agree with the idea of public healthcare, but not as a legislated monopoly.

There is no monopoly on health care in Canada: if you want to cut a cheque you can get private care. What is legislated is that if you take provincial funding you cannot also take private funds. It's either-or.

At least in Vancouver there are private clinics[0] where you can get MRIs, CT scans, endoscopies, etc within the week if you are willing to pay.

[0] e.g. https://www.timelymedical.ca/

> Monopolies don't benefit anyone except the monopolist

For healthcare in Canada, the monopolist is the Canadian people.

Are you making that decision because the quality of care you've received is better in the Canadian system than the American system, or because you disagree with how the American system is structured?

> Are you making that decision because the quality of care you've received is better in the Canadian system than the American system

That would depend completely on their job in the US. If they're a line cook, care was better in Canada. If they're a software engineer, it's better in the US.

It's not though. We have have ACA plans you get independent of employment and Medicaid for the unemployed.

Costs $20k for a family.

Just interestingly - the average per capita cost of Canada’s system is $4,000.

Of course in the US, there are costs beyond just insurance, but if you had to pay for coverage out of pocket it would be $16,000/yr for a family of 4.

Well the point is that you don’t have to worry about coming up with 20k if you leave your job in Canada.

Of course, but it puts the cost in perspective a bit if you did have to pay it out of pocket.

My "ACA plan" (Individual, bronze) through my state's exchange costs $2770 in premiums, which seems relatively good until you add the $8250 deductible. Now we're up to $11,020 for one person. Plus we're not counting whatever portion of my taxes also goes to healthcare expenses for myself or others already.

You're not supposed to be able to get private healthcare in Canada, but actually there are plenty of fancy clinics that will fix you up on the spot if you have money. It's all hush-hush because those in power are the primary users of that parallel system. It's not a criminal underground but an unregulated mezzanine, yes?

Also, in my experience, public healthcare _can_ be quite good, but the quality of service varies a lot across regions and institutions.

> It's all hush-hush because those in power are the primary users of that parallel system

Any hint you can provide of how to look into this? I know there are private clinics for certain things, but I would be very interested to see what options there are for my family

That was the part that pissed me off in Poland. Long story short, country moved to a very weird spot healthcare-wise, where, in theory, 'money would follow the patient'. Doctors did well ( cuz they tend to be smart and are well organized ); patients.. not really. I was young and very, very naive at the time. I figured that if the guys, who are voting for this have to use it, it won't be so bad.

I did not anticipate that they would grant themselves special kind of access to healthcare. Like I said, very, very naive.

> You're not supposed to be able to get private healthcare in Canada […]

Sure you are. There is no government monopoly on health care in Canada: if you want to cut a cheque you can get private care. Nothing illegal about it.

All (family) doctors in Canada are private businesses. It's just that most of them hook into the provincial payment system. Similarly for hospitals: they are not government run, just funded through government. If you wish to set up a private clinic and/or hospital and not take government funding, there is no legal impediment to do so.

What is legislated is that if you take provincial funding you cannot also take private funds. It's either-or.

> It's all hush-hush because those in power are the primary users of that parallel system.

It's not hush-hush, it's just most of us plebes cannot afford fancy pants clinics.

I don't know why the medicare for all plans need to ban private healthcare. Norway and UK has free healthcare for all, but still private options available for people that want to pay extra. That is also reducing the load on the public system so I can't really see why it is negative.

A lot of providers won't accept medicare because what they pay out is significantly lower compared to private insurance. That's why Obama's "If you like your doctor, you get to keep your doctor." promise was such a big deal.

As of 2020, only 1% of physicians opted out of Medicare[0]. That is an increase of only 0.3% since 2013. Furthermore, in my experience, physicians that opt out of Medicare refuse to accept any insurance, so the number of Medicare opt-outs is probably more of a proxy for opting out of insurance entirely. It is really not “a lot”.

[0] https://www.kff.org/medicare/issue-brief/how-many-physicians...

> If NY does this, the near zero chance of my moving there ever would go to absolute 0.

Are they proposing kicking you off your insurance? From the bill:

> SUMMARY OF SPECIFIC PROVISIONS:

Every New York resident will be eligible to enroll, regardless of age, income, wealth, employment, or other status. There would be no network restrictions, deductibles, or co-pays. Coverage would be publicly funded. The benefits will include comprehensive outpatient and inpatient medical care, long-term care, primary and preventive care, prescription drugs, laboratory tests, rehabilitative, dental, vision, hearing, etc. all benefits required by current state insurance law or provided by the state public employee package, Family Health Plus, Child Health Plus, Medicare, or Medicaid, and others added by the plan.

As someone that has lived in NYC for 15 years, I'd really love to see this happen.

Edit:

> Private insurance that duplicates benefits offered under New York Health could not be offered to New York residents.

So yes, I guess it would be kicking those off of their current private insurance. It sounds like it'd force private insurers to offer plans that would augment off of a base of public care.

I'm still fine with this.

I read through the bill and there are no specifics written on how the entire thing is supposed to be funded, other than saying that payroll taxes will be increased to fund it. My guess is that once the numbers come out on how much tax would have to be paid that this bill would be dead.

Companies currently provide health insurance and pay per employee.

Per employee costs go up due to health care payroll taxes.

Per employee costs come down due to not paying for health insurance.

Overall, net-neutral cost to companies and simplifies health care payments for hospitals, clinics, etc so fewer employees to explain and collect payments so cost of care comes down. Seems like a win - win - win.

Health insurance is a constant cost per employee, effectively decreasing in percentage of income as income goes up. Payroll taxes scale up as your income goes up. So no, it's not net-neutral as it's highly redistributive. If single payer were implemented as a flat tax, then it would be net-neutral.

Having it scale is fine imo as it fights against the overtime/overwork issue where since the health costs are constant it’s better to overpay and overwork one employee than to hire two.

If you follow this specific thread, the discussion looks like this

>>>> Person complaining about how his previous state-run health care system was awful

>>> Person replying that your current plan will still be there, no one will force you to take the state run plan

>> Person commenting on how funding for the bill will kill it

> Response that funding will come from the money that companies were paying on health plans.

So if everything in this one thread is true, then

- Companies will continue to offer the health plan they currently offer

- The state will provide a single payer health plan

- The money that companies currently pay on health plans will pay for both of those, with no increase in cost to the employee

Clearly that's not realistic.

It was later edited, but I think the bit where the thread diverges from your summary is

> - Companies will continue to offer the health plan they currently offer

I think the GP (GGP?) reading was that the current health plans would have to change; they can't duplicate the state mandatory coverage. (But they can build on top of it).

So theoretically a $1k/mo plan paid by the employer might turn into a $400/mo plan for extra coverage, and the baseline would cost $600/mo and that part would be taken over by the state. Best-case they can streamline that portion and decrease the cost through economy of scale; worst-case you have 2x the operating costs for two different insurance plans and the quality goes down because of the duplication and billing uncertainty for providers. (I'd hope that the bit covered by the state would be good enough for many people to have as their only coverage though).

Network restrictions are dumb, but copays and deductibles serve a purpose. Healthcare isn't unlimited, and free services leads to long wait times because people don't reduce demand (e.g. going to the doctor for a stubbed toe). Certain specialities already have enormous wait times. You're in NY, try seeing a neurologist for a non-emergency. Given that an enormous amount of first appointments are "come back in a month if this is still bothering you" - copays need to exist. Patients have to have "skin in the game" as Andrew Yang would say.

I live in Iceland. ETR is about 40% for me but I'm in a high tax bracket. None of the Scandinavian countries even have 60% marginal tax rate.

EDIT: My MTR is ~42% so my ETR can't be 40%. I don't have a payslip to calculate and searching the interwebs isn't helping a lot right now.

Same in Norway, max marginal rate caps out at almost 50%: https://www.skatteetaten.no/en/rates/maximum-effective-margi...

In a high-tax US state like California the top marginal income tax is about 47%. This covers no health care unless you are over 65, disabled, or are below the medicaid threshold, which is low.

There is also a lower rate om capital gains such as stock or real estate, sales (like a VAT), gas tax, vehicle tax, utility tax, phone tax, cable internet tax, etc.

Plus, of course, employers are paying some extra payroll taxes per employee.

I lived in the UK, Norway, Switzerland and US (NYC and Bay Area). Except Switzerland I did not really notice a big tax change for any of the others.

Sure in UK and Norway healthcare and University is free, but healthcare is provided by my employer in the states. So for me it is a wash.

But hey in the US I get to pay for the largest army on the planet.

What I would say is that in the US my taxes feel the most "unfair" since my tax rate is sort of the max. Richer people have ways of avoiding taxes and poorer people pay less tax.

This is a good criticism. High wage-earners in the US like a hardworking GP doctor pay the biggest effective tax rates.

> Coming from a country that has this, there should be caution

It's big world - without knowing which country, this is of little help. I'd like to see a comparison of people forced into debt, bankruptcy or death due to the respective medical systems

This hits home because I have a friend that got cancer with "good" U.S. insurance and if he did not fight the insurance company he'd be in debt for 1mm+

I'm from the UK, which is basically fully free-at-point-of-use healthcare (you pay a nominal fee for prescriptions, dentistry, optician) and is often championed as a great option.

Reality is it's pretty grim. Don't know if I'd recommend it to other countries to be honest.

Be careful what you wish for!

> Reality is it's pretty grim. Don't know if I'd recommend it to other countries to be honest.

As someone who's never experienced the UK health care system, and only know one person who has (as a foreigner, so they paid out of pocket and said the experience was positive, but otherwise not a good data point) ... I'd like to hear a bit more detail about how it's pretty grim, if you're willing to elaborate.

I'd love to get you to listen in to a phone call where I try to get an appointment with my doctor. You'd have to be up at 0800 on the dot, while I desperately try to get into the phone queue. Then you'll hear me beg with the world's rudest receptionist for an appointment, which I won't get.

There's no incentive for these people to be helpful or polite, because they get paid anyway and there's no market, so they aren't.

My American colleagues see a doctor every year for a checkup to catch things like cancer before they're fatal. The NHS would laugh in my face if I said I wanted to see a doctor for a checkup, unless I literally had an arm falling off.

You don't have a yearly physical with your GP under NHS?

Also, I just spent a total of seven hours last week making calls just to get insurance to even process my prescription that they had previously approved.

There's no way in hell an NHS GP would agree to see me just for a physical without some very specific major problem actually in evidence.

If you never want to see your GP again then yeah petition for the UK system.

What does a "check up" mean?

There's no way my insurance would pay for random "I don't think anything's wrong but I want to look for something anyway" outside of yearly physicals either.

> outside of yearly physicals

Yearly physical == check up. Same thing. Going to the doctor once a year for a general check that you aren't developing any issues that you weren't aware of yet and to monitor your health.

I don't have either. I haven't seen a doctor for about five years I think, under the NHS system.

If I phoned my NHS GP and said 'it's been a year I'd like you to generally check my physical health' they'd tell me to fuck off.

Looks like the official NHS policy is that you get a checkup every five years if aged 40 to 74. https://www.nhs.uk/conditions/nhs-health-check/nhs-health-ch...

I'm not a doctor but that doesn't seem often enough for an older person. I'm an American in my 30's and I just had a checkup, and my doctor told me to come back every two years. Of course the American system is pretty awful in its own ways, especially for those who are uninsured.

Preventative care is $0 as a part of the ACA and reputable physicians are included.

Similar to the UK, my in laws in Canada can’t get annual physicians scheduled either - there needs to be something wrong before a doctor will take an appointment.

I'm glad ACA coverage is available but it can be pretty expensive. I paid somewhere in the range of $300-350 per month as a healthy young person. Some of my friends went without insurance for years because they simply couldn't afford it.

There are a lot of problems with the NHS. The GP booking systems are diabolical at the moment, as you point out, and GP receptionists are up there with post office staff for aggressive service. I personally use Babylon GP at Hand and am very satisfied, but that's only available in London I think.

That said the reason we don't do as much in the way of screening and yearly physicals of young healthy individuals is because there's very limited evidence that it's even helpful and sometimes even evidence that it's harmful.

That isn't to say they don't sometimes save a life, but they also cause unnecessary medical procedures and needless medical anxiety. What kind of early cancer detection is really happening at a yearly physical? You could argue that a doctor telling you to lose weight might help reduce obesity or diabetes, but so far that doesn't seem to be working.

Even if you do catch and treat a cancer, was it a slow progressing cancer that never would have caused an issue for the patient? This is particularly significant when you're looking at someone in their 80s.

If you have any health conditions, have a family history of disease, are taking repeat prescriptions or are above 40, you will start being offered regular checkups and screening.

You can also book a private GP or checkup if you want, or even just pay for a periodic blood test. The NHS/NICE has decided the evidence base doesn't exist to support it, but you're free to decide otherwise if you wish.

Most Americans can't afford to go to the doctor for their yearly checkup, and most don't. A large percentage of the country doesn't have insurance.

Also, I'm actually not sure that a yearly physical in the US does much for cancer screenings. The last one I had in the US did blood tests for cholesterol, urine tests for kidney disease, and some other common tests, but I don't remember getting screened for forms of cancer. I think this is dependent on the healthcare provider you go to, and what your insurance covers.

I'm from the US born and raised, so I could talk at lengths about how the healthcare system here bankrupted my parents and nearly forced me into generational poverty. Or how poor the care is despite being under decent corporate healthcare. Or how misaligned the incentives are resulting in doctors suggesting nonsensical treatments like holistic care rather than actual treatment.

Most people don't encounter this stuff until it's too late, which is partially where all the praise comes from for the American healthcare system in my opinion.

> doctors suggesting nonsensical treatments like holistic care

Did you know that until 2017 the NHS literally funded homeopathy?

I'm not even joking.

UK does not have single payer, their system is nationalized. Big difference, especially with capitated plans that medicare is championing. Competition is what makes capitalism great, single payer is the best way to accomplish it among medical providers.

The NHS is about the only thing this country has that I am even remotely proud of. It is far from perfect—made substantially worse by the last decade of Conservative austerity and piecemeal attempts at privatisation—but the idea that you’d be so disparaging is crazy to me.

I had cancer five years ago, spending the better part of six months receiving inpatient treatment, during which I couldn’t work. I had recently moved jobs beforehand too—I have literally no idea what I would have done under an American-style system.

It’s bursting at the seams (through no fault of its own), and yet still we never bankrupt people with life threatening illnesses, we don’t bill people for ambulances, we don’t force seriously ill people and their families to do battle with blood-sucking insurance companies over byzantine coverage terms.

It’s the last damned thing this nation has actually feels like it exists for the common good of the people. I would recommend it to other countries—wholeheartedly.

I understand where you're coming from related to this. We (in the US) hear this critique with regards to the NHS or the Canadian healthcare system.

The part you're missing is that there is an arms race of pricing between healthcare corporations (there have been massive mergers of hospital systems) and insurance companies in terms of prices. We, the patients, are caught in between the giants while prices are going sky high and we are at our most vulnerable.

The hope is this will fix prices to a reasonable level so if we choose to go for private care, those prices will also be reasonable. A lot of specialists that I see ask for cash payments and don't accept insurance. They are also overbooked because a lot of healthcare providers are being driven out of industry from the conditions.

I come from a country with universal healthcare too, and my experience is the opposite.

Yes, to this day, it doesn’t cover dental or vision, which is BS if you ask me, and there is some co-pay for certain prescriptions; regardless, it is a fantastic system, and I miss it so much every time I need to go to the doctor here in the US. The main reason is uncertainty: in the US, I can never know how much something is going to be, even if it starts as a mere visit to a family doctor, because there are uncountable variables that may factor in the final cost.

As a result of this, I try to avoid going to the doctor as much as I can, and it makes me think about all the people who really cannot afford healthcare, and don’t qualify for Medicare either.

> I can never know how much something is going to be

I think the closest thing you can get to the cost experience of universal healthcare in the US is one of the better HMO providers like Kaiser. Everything is a known cost up front.

Most Americans have never experienced a system like that, and will fight tooth and nail against things they don't understand or have experienced. They are told by billionaires who run the media empires that universal healthcare is expensive, will ruin the country, will remove their ability to get appointments scheduled.

Of course coming from any other country, this is ridiculous. But it goes to show you how out of touch many Americans are with how the rest of the world works.

>Most Americans have never experienced a system like that, and will fight tooth and nail against things they don't understand or have experienced. They are told by billionaires who run the media empires that universal healthcare is expensive, will ruin the country, will remove their ability to get appointments scheduled.

My wife, a practicing physician, did fellowships in multiple countries like this.

I asked her for her opinion given her experience with their systems, and our systems, and also being on the provider end.

"excellent emergent care, comparable to better US hospitals"

"horrible waiting periods for elective care, and non-emergent surgeries"

The US also has terrible waiting periods for elective care as well. I've talked to many physicians in the US (wife is MD) and you're booking way out anyways. So...universal healthcare has wait times of 7 months instead of 5 months.

It's just weird how people argue for the US system as if it's superior but it really has the same problems as other countries with even more downsides. If we're supposed to be "good" at elective surgeries we're giving up a lot to be pretty mediocre.

Many socialized systems have wait times of years, not months for elective, and non-emergent surgeries.

>"horrible waiting periods for elective care, and non-emergent surgeries"

Same as in the US. Three months is the minimum.

Hell, I couldn't even schedule a tooth cleaning with a new dentist less than six months out - I called close to 10 dentist offices.

> Same as in the US. Three months is the minimum.

big nope.

Wife is booking emergent same day, and depending on the case length and type, 1-2 weeks for most cancer cases, up to a month for a complex deep inferior epigastric perforators flap breast reconstruction surgery which is a long surgery if bilateral; getting that much OR time is a challenge. They'll book for saturdays if they need. Cases that can be done in a surgery center are quick; major cases that require a hospital OR, and other physician clearances take longer to coordinate.

The longest backlog (1 year) in the practice is actually a 99% cosmetic plastic surgeon who is an instagram famous Michelangelo of Brazilian Butt Lifts.

Way to deny people's lived experience.

I can corroborate the GP's experience of having to book several months in advance for non-emergency care—the fastest medical booking I've had in the past several years is surgery for my cat, which was about three weeks.

It sounds like we have different experiences due to the local/regional availability of physicians.

Certain areas of the US, particularly many big cities have a plethora of physicians and active competition between them.

Why are you telling me that my experience is somehow invalid?

Your experience sounds anecdotal.

"They are told by billionaires who run the media empires that universal healthcare is expensive, will ruin the country, will remove their ability to get appointments scheduled"

The "billionaires" aren't lying to you. Look at the UK, a maximalist interpretation of universal government funded healthcare.

Lockdowns destroyed the NHS. The waiting list for care (not even just elective care, any care) is now closing in on 10% of the entire population!

https://dailysceptic.org/2022/04/15/lockdown-backlog-nhs-wai...

People are waiting hours for ambulances to turn up after heart attacks! People are dying inside ambulances sitting in queues to enter the hospital. My family has largely given up on seeing local general practitioners because so many have reduced hours during lockdowns and never brought them back, meaning they're working less with bigger demand due to backlogs. The system has indeed removed their ability to get appointments scheduled.

These are third world conditions, or perhaps more accurately, second world conditions - nobody has to pay but there are severe shortages all the time, and what you get may or may not be of acceptable quality. The USA doesn't have these problems. Heck, most places that aren't fully government run don't have these problems.

The problems are cutting through. My aunt, a lifetime public sector worker loyal to the NHS, was talking about getting private care last time we talked. It was a surprise but she said her experience was you just can't see doctors without it anymore. The net result is going to be a very expensive healthcare system for the UK - high taxes to pay for the NHS plus an ever larger shadow system of private healthcare on the side.

"you get what you pay for"

No country pays more for healthcare per capita than the US. If we could capture some of the huge chunk that goes to private insurance companies (each company has its own redundant staff and technology systems, their own execs all getting their own bonuses, etc), we could provide healthcare even better than we already provide in the US to those who can afford it or qualify for public programs.

> their own execs all getting their own bonuses, etc

While we love to critique big insurance, and some of it may be earned, that industry is not known for the skyhigh profits OR margins like IT is.

Here is an HMO for ya

> OAKLAND, Calif. — Kaiser Foundation Health Plan, Inc., Kaiser Foundation Hospitals, and their respective subsidiaries (KFHP/H) reported 2021 annual financial results. Total operating revenues for 2021 were $93.1 billion compared to $88.7 billion in 2020. Total operating expenses were $92.5 billion compared to $86.5 billion in the prior year. Operating income was $611 million, or 0.7% of operating revenues, compared to $2.2 billion in 2020. Increased care delivery expenses due to COVID-19 surges contributed to the decline in operating income.

> “After almost 2 years, the COVID-19 pandemic continues to impact Kaiser Permanente just as it does our daily lives,” said chair and chief executive officer Greg A. Adams. “We rapidly rolled out vaccines, and now boosters, and administered more than 9 million COVID-19 tests while managing new and unpredictable variants like delta and omicron as they surfaced. Throughout this crisis, gratitude goes to our dedicated employees and physicians who have remained focused on providing care and strong support for members and communities.”

> Like other organizations, Kaiser Permanente benefited from strong investment performance due to robust financial markets during the year, resulting in total other income and expense of $7.5 billion compared to $4.1 billion in 2020. This sharp increase in investment performance more than offset the $1.6 billion decrease in operating income, resulting in 2021 net income of $8.1 billion compared to net income of $6.4 billion in 2020.

> Capital spending totaled $3.5 billion compared to $4.0 billion the year prior. During 2021 Kaiser Permanente opened 11 medical offices. Kaiser Permanente now includes 734 medical offices, 39 owned and operated hospitals, and 58 retail and worksite clinics.

and regular insurance

> United Healthgroup Profit as % of Revenues 6%, Profits as % of Assets 7.8%, Profits as % of Stockholder Equity 23.5% for CY2021

Switzerland has private insurance just like the US and people I know that live in Zurich love it.

It's not exactly like the US tho. Basic insurance is mandatory for every resident, insurers can't refuse covererage (no preexisting conditions) and pricing of insurance is transparent (I don't think they can differentiate beyond a few variables).

Afaik pricing of medical procedures is defined by government (probably with insurers and practitioners).

It's high quality but fairly expensive (relative to GDP or salary vs other European countries)

> Switzerland has private insurance just like the US and people I know that live in Zurich love it.

Profits are regulated (sometimes down to zero) in CH. Profits are unregulated in the US.

Only for the "soziale krankenversicherung" or basic plan.

US has a massive free healthcare system called "Medicaid" which is similar to the basic plan for low income individuals and families, the scale of which is unknown to many:

> Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States, providing free health insurance to 74 million low-income and disabled people (23% of Americans) as of 2017, as well as paying for half of all U.S. births in 2019.

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

In addition, each state has other provisions. For example, California's Medical system is used by a third of California's population:

> Benefits include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder treatment, dental (Denti-Cal), vision, and long term care and supports.

https://en.wikipedia.org/wiki/Medi-Cal

US health insurers are required to spend large majority of revenue paying claims, which does not cap profits absolutely but does proportionately.

Given that you were already unlikely to move to NYC, I’m not sure your opinion has much weight compared to that of existing New Yorkers…

Coming from Turkey that has this, I can 100% vouch for it. Prescriptions are partially covered. Private insurance and private hospitals is an option but that doesn't mean state hospitals are bad. Healthcare quality is very good in state hospitals. It's actually one of the only two categories in which Turkey's in a good standing among OECD countries.

It has its own wrinkles of course. For example, doctors make less money and their working conditions are worse than private hospitals. Because of that, it's common to get asked to pay a "knife fee" in secret for operations. Some doctors ask for an expensive bottle of whiskey etc. I haven't experienced this myself but heard about those incidents many times.

However, wait times aren't long. Appointments are organized electronically through E-State portal. Although wait times in ER can be long based on your triage, that's the case with United States anyway.

The benefits of single payer healthcare outweigh the drawbacks by a wide margin. You never worry about unemployment. You don't have homeless people due to their mental problems as they're treated in mental clinics. You don't worry about "getting bankrupt" suddenly from an unforeseen health issue. Healthcare costs are low even if you're not insured. That means drugs are cheap even though state won't cover 100% of the cost. Even private insurance is cheap (~$1000 a year).

Yes, taxes are high in Turkey, but healthcare system costs make up a very small portion of it (~5%).

The US spends more per capita than other countries on healthcare.

But that doesn't mean the US would have to pay less per capita in a single-payer system.

So we could keep getting what we pay for in terms of capacity, etc, if we want. You would expect a wealthy country to be able to pay a premium to get a premium.

> Coming from a country that has this, there should be caution: it gets more affordable, but you get what you pay for. In my country of origin, you get a partially-paid-for ride to the emergency room, where you pay for things like casts, non-ward rooms, dental care out of pocket.

New York State will not necessarily implement the same program your home country has.

> Since moving to the US, it is more expensive (than next to nothing), but I actually get good care. Several conditions that were ignored or misdiagnosed for me are now cured. My life might be significantly shorter had I not come here.

It's not really news that the (relatively) rich can get better things by paying more. The well-known consequence of the US system is that many people get no care, because they don't have the money to afford it. That includes people with health insurance, which often doesn't pay for anything at all until you've paid thousands out-of-pocket to hit your deductible.

I’m an MD who trained in NYC. I have also had emergency surgery in the NHS at one of their most prestigious hospitals in London and so I feel like I’ve seen the system a little bit from the inside.

It was far cheaper for me than it would have been as a Brit in the USA, but the standard of care was lower. They didn’t have some technical and staffing resources late in the afternoon that would be a baseline in any of the hospitals I’ve been at in the USA. The English doctors were just kind of apologetic and bashful about it, talking to someone they knew was an American doctor who knew what kind of specific diagnostic algorithm was appropriate.

The NHS hospital did have really excellent amounts of ancillary staff. Someone brought coffee and tea to me like 3-4 times a day, it wasn’t hard to get my luggage delivered to my bed, etc. Not like that in the USA from what I’ve seen.

The NYC hospitals are somewhat financially strained as it is. Especially the public hospitals (Bellevue, Elmhurst, Metropolitan).

Also related would be care at the VA hospitals, which is slower/worse than care at NYC flagship hospitals. But as a society we don’t want to prioritize or pay for good care for veterans, so it is what it is.

I predict this will continue to basically just produce a more two-tiered system in the US. Most doctors who have a choice (large group practices) will take the wealthy patients with private insurance, and the big hospitals and whomever else who don’t have a choice will be forced to accept the NY single payers (basically the existing model, where the poor and 65+ are already covered under Medicaid and Medicare already). It will likely strain these systems even further, as reimbursements from Medicaid/Medicaid are insufficient to run large health systems which depend on higher rates from private insurers (payor mix). Good luck there.

In NYC even more physicians and group practices will try to go to alternate models such as cash-only. Try being on Medicaid or Medicare and finding an outpatient psychiatrist in NYC now as it is. This will extend to more PCPs, chronic disease specialists, etc.

Some patients will get better and more affordable care, but some will also get much worse care. It will be interesting to see what happens. I’m not necessarily opposed, but this is absolutely not going to be a clear and decisive win on all fronts as some commenters are suggesting. The US healthcare system, if you have private insurance, is the best in the world already in terms of level of service and access to rapid specialty and high-end care.

If we go by data, the US healthcare system is the most expensive (not arguable) and is not even in the top 5 among developed countries in the most important measures. Also a doc, though that is not really relevant for this discussion.

one of these references is from an US insurance company who you would think would be biased for US healthcare

https://www.cignaglobal.com/blog/healthcare/top-10-countries...

https://www.washingtonpost.com/world/2021/08/05/global-healt...

https://www.internationalinsurance.com/health/systems/

I said “if you have private insurance,” which I think is the key qualifier. One of the other commenters expanded upon it well below.

I’m not making an argument for cost-effectiveness either.

We can get private insurance to pay for elective surgeries, new medications, etc. that are either not covered in other countries or have extremely long wait periods. And the higher reimbursement I think is helpful for providing staffing and paying for equipment that they (in my admittedly n of 1 experience) simply didn’t have for me. I suppose it is a tradeoff.

This is a good take. Single payer might work in the USA using HMO plans funded by taxes, income/asset linked tiers of coinsurance, tax increases, major efficiency corrections, reduced barriers to entry, and mix of deregulation and regulation to increase competition.

Also, the US healthcare system is the excellent and one of the world's best if :

A) you have good insurance or medicaid/medicare in the right place.

B) you have transport to potentially drive some distance to deal with occasional wait times or to find in-network providers

C) you can navigate the sometimes byzantine billing nightmares that can occur where your coverage is denied on medically necessary or contractually covered care; or your enrollment in a subsidized program is denied, late; or you are indigent, incapacitated or elderly need an advocate to assure you get enrolled in correct coverage.

Great points. Yes those are the major barriers. If you have all those, things can go well. Obviously heaps of people in the USA do not.

So it depends what you mean by 'best'. In most developed countries, if your situation is ideal you can get fantastic healthcare, and that seems to be the point you are making.

There are some niche fields where the USA is demonstrably the best - pediatric oncology surgery, some difficult transplants, and novel cancer therapies come to mind. But I think it is hard to argue that it is anywhere near the best on the metrics usually used to judge a healthcare system, which other people have posted about.

In my experience, it also suffers from thinking it is the best and patients expecting it to be best. I have seen some patients get quite excessive and even unusual treatment in hallowed healthcare institutions in the USA.

As a not doctor I don't understand this:

> It will likely strain these systems even further, as reimbursements from Medicaid/Medicaid are insufficient to run large health systems which depend on higher rates from private insurers

Time ran an article a few years ago about hospital billing and whatnot. One of the things that they pointed out was that Medicare reimbursement rates were based on the actual cost to provide the service. If the problem is that Medicare doesn't pay enough extra to subsidize indigent care then having medicare-for-all would address that as it would reduce the number of uninsured.

> In NYC even more physicians and group practices will try to go to alternate models such as cash-only. Try being on Medicaid or Medicare and finding an outpatient psychiatrist in NYC now as it is. This will extend to more PCPs, chronic disease specialists, etc.

As opposed to what's already happening? Keep in mind that the southeast part of San Francisco already has relatively poor access to health care. A few years ago Sutter decided to revamp Saint Luke's hospital in Bernal Heights. St. Luke's used to be a community hospital where you'd go for primary and emergency care. Sutter changed that all up and stocked the offices almost exclusively with specialists (because that's where the money is).

> The US healthcare system, if you have private insurance, is the best in the world already in terms of level of service and access to rapid specialty and high-end care.

I'm sorry, what? Back when I had Blue Cross/Shield I had to book an ultrasound something like three months in advance. In San Francisco. At the time I was seeing a fee-for-service GP. If I'd wanted to switch to an in-network GP the wait at UCSF was like nine months. Finding a GP that takes both new patients and insurance was not easy – in fact I didn't as my GP was amazing.

1. It’s just a fact that if all reimbursement was currently Medicare-level, the existing hospital systems in NYC would run a massive deficit and couldn’t provide the services they do now. They wouldn’t be in business barring massive reductions in staffing, hours, services, salaries, etc.

I don’t know what you read in the NYT but this is well-known in healthcare. Hospitals lose money on Medicaid/Medicare patients in general and make it up on private insurance (also in general) in order to hopefully pull in a surplus each year. Look up the idea of “payor mix.” Private insurance reimbursement varies widely but is typically a multiple of Medicare/Medicaid.

2. Yes - it is already happening. I think it would likely get worse. I don’t think single payer insurance is going to cause a renaissance of PCPs, especially if the overall reimbursement for that kind of service goes down. Probably the other direction. Maybe I’m wrong.

3. I’m not exactly sure what happened at UCSF with your ultrasound. Not familiar with SF really. But you can look up mean wait time for most elective procedures in the USA vs. Canada or USA vs. the UK. Or access to new therapies.

From my experience working at a private insurer, (1) is, unfortunately for the body politic, more complicated than meets the eye.

The payor mix narrative has attractive qualities: it makes the private insurance companies sound like they're subsidizing care, the logical implication is that if we made these atlases shrug with M4A, the local PCP would go bankrupt. In reality, the narrative is at best reductionist and at worst misleading. But it rhymes with the truth, so it has a lot of mileage.

Private insurance reimbursements are negotiated in multiples of medicare because insurers and hospital groups alike expend tremendous amounts of money each year in administrative costs to challenge claims back and forth.

A surprising proportion of private insurance payouts are never reimbursed at the negotiated price. But hospital groups are OK with this, because it allows them to deduct the difference as a loss. Accountants rejoice!

Medicare/Medicaid prices are "low" because (1) the government has a strong bargaining position, (2) the population served by those fees has confounding variables of age and disability which raises the relative price of care (3) the government does not play claim-challenging games anywhere close to the extent of private insurers.

Private insurance companies and big hospital groups benefit the most from the status quo, and have the most to lose from medicare for all. But it would not be doom and gloom.

Medicare can adjust their prices to match the new population and tax base, hospital groups can stop running mini debt collection agencies, etc. There are real cost savings in M4A.

I think what's most likely to happen is an expansion of medicare advantage, (ma4a?). Since it's a program that effectively nationalizes the existing regime of private insurance.

> I don’t know what you read in the NYT but this is well-known in healthcare.

Time Magazine, not the New York Times. I don't know what you think but it's commonly known that the chargemaster is indeed bloated to cover things like indigent, uninsured patients. Here's the thing, people without money use the emergency department for primary care because they cannot be turned away. That's expensive. Getting those folks covered and away from the ER absolutely reduces costs.

https://time.com/198/bitter-pill-why-medical-bills-are-killi...

> By law, Medicare’s payments approximate a hospital’s cost of providing a service, including overhead, equipment and salaries.

So I'm not sure what you're talking about. Obviously Medicare doesn't exist to guarantee a profit. Whatever fee schedule is negotiated with private insurance companies does not actually reflect the cost of providing a service – the negotiated rates include things like profit and taking care of patients who can't pay.

> I’m not exactly sure what happened at UCSF with your ultrasound. Not familiar with SF really. But you can look up mean wait time for most elective procedures in the USA vs. Canada or USA vs. the UK. Or access to new therapies.

Dunno what to tell you. My experience was back in the mid-00s, and I doubt anything's improved since then. It didn't then (and doesn't now) take much effort to find people struggling just to find a doctor that takes insurance. I couldn't tell you why UCSF was so short of ultrasound techs, but yeah I potentially could've found an outside (but still in-network) provider on shorter notice. But then I would've been on the hook to deal with insurance billing hell. Even (especially) with UCSF I was getting screwed by their chaotic billing. Labs that were part of an office visit were officially covered by my insurance but as they were billed separately they were not considered part of the office visit (and therefor not covered).

https://www.beckershospitalreview.com/hospital-physician-rel...

Average wait time for an appointment as a new patient 24 days, worst metro area was Boston at 52 days. 45 days to see a cardiologist in Boston, 51 days to see an ob-gyn in Philly. We're already rationing care (by financial means instead of need), and that's largely due to insurance.

While there was a multi-month waitlist for a GP that took new patients and insurance, the fee-for-service practice I used could typically schedule even new patients same day or same week at least. Hell, their rates weren't even obscene as their practice was almost entirely MDs and a single receptionist. They didn't have to fund an army of people to battle insurance bureaucracy. Over the years my GP went out on her own practice for a bit, and then as her circumstances changed she went back to a practice she'd been with years before. From a patient POV the biggest problem she had was finding competent non-degreed office staff.

I can't say for certain that single payer (or even just a dominant federal government run system) would crate a "renaissance of PCPs", but anything that reduces the administrative burden will reduce the cost of running a medical practice and by extension will reduce the urge to focus on specialties.

I'm on NY State insurance rn while unemployed and it fucking owns. All the doctor's appts and procedures I've had the last year or so have been amazing, mostly through Langone, and the doctor's have been super thorough and attentive.

It's the highest number of (much needed) appts Ive had in the last 10 years combined and at 0 copay. Yes, taxes, but idgaf seeing as the private employer based insurance I had took a big chunk out of my checks, had to pay co-pays, and I had to pay out the ass for my prescriptions.

This is a huge win if passed for anyone in the state, regardless of income, seeing as it would be a huge safety net. The rug could pulled on anyone of any background tomorrow, yet they'd have their covered in the best way possible.

Fuck, I hope this goes through!

Nice. Yeah maybe this will be a win. I’m overall more for it than against it. Just think there are some downsides. Glad to hear you have had a good time on the NY State insurance. Is it Medicaid? Langone actually has the best (most private) payor mix of any of the hospitals in NYC, I believe primarily from geographic reasons. Did you get to compare to Bellevue at all? Curious on your perspective there. Hope you’re doing okay.

Thanks man. Doing alright and hope the same for you.

It is medicaid and Langone's network is actually spread throughout the city, even at Bellevue! Actually got an appt there coming up and the Dr I'm seeing there has been the best. Top notch

There's guaranteed to be risks and downsides but the status quo is utterly unconscionable so I will take absolutely any step in the right direction.

I don't think the NHS is a great example... things can surely be better than that.

Incentives are a complicated issue in healthcare. In Australia there is a 'two-tiered' system in the sense that there is a large public system funded federally and by states that provides access to anyone and everyone, and a private system where most people have private insurance and also pay additional fees. There is no insurance linked to employment.

Primary care can be accessed for free or depending on where you live, often involves paying a gap for each visit.

What doesn't happen is that all the best and most experienced doctors/nurses go and work in private. Almost all the doctors worth seeing work in the public system as well. Why? Well, it differs for each person but some combination of status, access to a professional network, collegiality, access infrastructure and expertise, job flexibility and the fact that it acts as a referral stream to 'take patients private'. The facilities in the public system are 'the best' becaue they still handle all the complicated and difficult care (Oncology, Transplants, Dialysis etc), despite what the private hospitals say in their brochures.

My point is that if you make some adjustments, bake in some infrastructure funding, and make smart use of non-financial incentives, you can avoid creating a two-tiered system and build enduring capacity and quality in a single payer system.

With California and New York both exploring statewide single payer healthcare it looks like the Overton window is moving closer to legitimate discussion of a nationwide single payer plan in the US. It’ll be interesting to watch, since this is such a hot-button topic here on many levels.

as long as these plans can negotiate and also use their market power to reduce the prices that healthcare services charge to Americans, but starting within their jurisidction

a significant portion of the consensus failings have been because simply having insurance for all is just a bandaid, and this has been an accurate criticism of one party's tax and spend trend whether that seems like a conversation derailing political statement or not

It is dead in the water. The Republicans show no sign of supporting broad non means tested or non age gated taxpayer funded healthcare, and they hold the cards in the US Senate.

On the state level, any broad based benefit that does not discriminate is also futile because benefit recipients can move into the state and payers for the benefits can move out of the state.

See Vermont for the previous trial of this:

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

It the same problem with homelessness, education, and mental healthcare (a subset of healthcare). Without a border to limit the ratio of net benefit recipients to net payers, the numbers will not work out.

You really think people are going to flee NYC and the large cities in CA over this?

Anecdata but I personally know more than a few people who moved to Nevada to avoid California taxes, so yes.

And I personally know more than a few people who have moved from flyover states to California. Goes both ways.

The relevant question would be the ratio of the movement of net payers to net benefit recipients into the system.

OP sounds to be arguing the opposite. One lives in a low tax state while earning money / paying taxes, then retires to a rural part of NY / CA to receive tax-payer-backed benefits without paying for them.

Retirees usually use Medicare.

Having a bunch of (medicare-covered) retirees (with no school-age kids) spending their (taxable) social security income in NY / CA sounds pretty great. Much better than losing them to Florida or Arizona. Bonus if the states get to tax their estates in the end.

The fact that they are Medicare covered means the retirees will choose to retire in lower tax jurisdictions. They do not need state governments to provide healthcare.

I think he means people who have enough money at, say, 40 years old, to pay for everything but health insurance. I can see the temptation myself, since insurance as you get into your 50s can be 2000/month or more. If NY State pays that while I wait for Medicare to kick in, hey, FIRE!

Half of California's tax revenue comes from the top 1% [1]. Medicare retirees are almost guaranteed to not be part of that 1%. You're talking huge tax revenue losses here if the 1% do decide to leave.

[1] https://lao.ca.gov/LAOEconTax/Article/Detail/7

California is the fifth largest economy in the world. New York State's GDP is roughly $1.5 trillion, 8 percent of the U.S. total. They are resourced at levels of entire OECD countries that offer universal healthcare.

If Congress can't get its shit together, states that can should.

https://www.politifact.com/factchecks/2015/sep/01/dan-gecker...

https://web.archive.org/web/20160107120644/https://www.who.i...

30% of the US federal budget is healthcare spending.

https://www.usaspending.gov/explorer/budget_function

And that is only because a ton of people do not actually get healthcare, either because deductibles dissuade them or they do not pass the means testing to get enough subsidies to buy Medicaid or healthcare.gov insurance.

And that is because Medicaid severely underpays doctors to the point that if you visit a US city subreddit, one of the frequently asked topics is "where can I find a doctor that will accept Medicaid".

I think this issue can be too big for even NY or CA. It seems like it is for the US federal even, such that the political will only exists to provide healthcare via extreme price segmentation/discrimination. But most importantly, you can surely have your high risk pregnancies and hemophiliacs and cancer or whatever other high cost patient population move to the state, and the price tags on those patients is nothing to sneeze at.

Very broad strokes, doctors in the US are overpaid and conservatives legislated Medicare can't negotiate drug prices. Lots of room to drive down costs. Spending is high because of a dysfunctional system driven by profit instead of care.

https://www.npr.org/sections/money/2019/03/12/702500408/are-...

https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010....

https://www.bostonglobe.com/2021/10/25/opinion/let-medicare-...

https://www.brookings.edu/research/a-dozen-facts-about-the-e...

https://www.commonwealthfund.org/publications/issue-briefs/2...

Sure, and the US doctors I know tell me they tell their kids to NOT become doctors due to the high education cost (not just in money, but in years) relative to quality of life at work and compensation, which are both decreasing.

There's a myriad of factors here, but at the very root of it all is that there are a lot of people in the US that could use healthcare they cannot afford, but I do not see the political will for the wealth transfer required to get it to them.

Even in the countries that do have free healthcare, I believe there are cracks forming due to decreasing proportions of the population of young people (net labor suppliers into the "system") versus the increasing proportions of populations of older people (net recipients of labor).

Part D is federal subsidies for private insurance, the companies that offer those plans choose what drugs to cover and negotiate prices and so on.

If you don't want private companies to be involved in that coverage that's fine, but the whole Medicare can't negotiate prices is such a weak talking point, obfuscating the issue for cheap points.

Agree with the part about doctors being overpaid in the states. My wife is a 3rd year resident of a fairly well-known hospital system in one of the biggest metro areas of the US. We always feel lucky that she is a doctor because we know that she will make $250K+ (more like $300K/year if she choose a hospital in a rural area) as an internal medicine doctor (hospitalist/attending). My wife might go for oncology fellowship and that might put her earnings close to $400K+/year after 3 years of fellowship training (during the fellowship, she will make ~$80-90K/year). We get very good health insurance from her hospital since she started her residency there. I myself quit medical school after 2 years because I hated the way I had to study to get good grades there (a lot of rote memorization). But looking back, I regret quitting.

Both my wife and I agree that if we ever have a kid, we'd encourage him/her to at least consider medicine as his/her profession (assuming that the US healthcare system stays the relatively same). We are NOT the only ones. There are so many doctor friends of ours whose parent(s) are doctors. Our friends also think the same as us (that they'd encourage their kids to consider medicine as a profession).

Medicine is great because once the loans are paid down doctors have plenty of job options to get the right fit.

That being said the system of training is a ridiculous and discriminatory waste of human potential. Eight years of study with giant amount of vacation is just abhorrent. 18 year-olds who want to be doctors need 48 weeks of school per year like a military medic or any normal adult. What a joke college is in the US. And the residencies are flat out nonsensical illegal discrimination. If a woman wants to have a baby every year while she can, there are many types of medicine where there is zero reason to require 24 hour residency shifts, yet they basically coerce it anyway. Similar for a disabled trainee or just anyone whose training need not include such things. Heck, even a trainee with a bit of sleep apnea or a sleep disorder should not be forced to destroy their cardiovascular and mental health unless shift work is a necessary component of training for the respective discipline.

We already have a shortage of doctors and it is very expensive to become a doctor. How will paying doctors less help this? We need to reduce requirements for becoming a doctor and have "tiers" so people who just do family doctor things only need to know family doctor things.

Prescription drug spending is less than 20% of medicare. Negotiating prices might help but taking that 20% to 10% still leaves healthcare as a very very large expense (source https://www.commonwealthfund.org/publications/issue-briefs/2...).

We could forgive the school debt of existing doctors and pay the entire cost (with appropriate cost controls) of medical school for new doctors.

> We need to reduce requirements for becoming a doctor and have "tiers" so people who just do family doctor things only need to know family doctor things.

The fact that you think family medicine is about "just knowing family doctor things" tells me all I need to know about your level of medical knowledge.

Family medicine is arguably the field with the highest knowledge ceiling, because they have the first encounter with literally anything the patient can present with.

Lowering standard and having NPs write adderall(have you heard the news about those ridiculous ADHD online clinics? btw people don't seem to appreciate that adderall is functionally meth) and antibiotics for everyone they set their gaze upon is not the right way to improve healthcare.

We have a shortage of doctors because the government artificially limits the number of residency spots which are required to become a doctor. Double the number of residency slots and med school spots will follow. Even if you halve doctor salaries I guarantee you we will have twice as many new doctors per year. The cost is not even close to what is stopping people from becoming doctors.

There was a bill in California pretty recently, it was killed without a vote in the full chamber [1].

The window-breaking-and-repairing industry is too powerful for us to stop it, unfortunately.

[1] https://www.npr.org/2022/01/31/1077155345/california-univers...

Something is going to have to change. As it stands, there isn't a plan on the national insurance exchange that I can buy that's even remotely as cheap as my company's plan (actual premium, not just the fraction paid for by employee).

Probably because your company can negotiate and control the population characteristics (unlike the exchange). Or is self-insured, meaning they aren’t profit motivated.

Insurance on average is always more expensive than not having insurance on average. The question is given that risk, how much of a premium can / will insurance companies take. Turns out they like high profits and low risk.

Are health insurance companies allowed to discriminate customers by their health status, that includes age? With a good deal of populace morbidly obese and not even bothering to exercise, it's expected that healthy 25 yo are going to pay crazy insurance payments. Corps, on the other hand, absolutely do discriminate by all sorts of characteristics and insurers know what they are signing up for. Offer health insurance tiers by age and BMI and watch premiums getting reasonable again (for some).

No. Per the Affordable Care Act, since 2010 health insurance companies can only price insurance based on age, smoking status, and location. And they must offer insurance to all.

https://www.healthcare.gov/how-plans-set-your-premiums/

> Offer health insurance tiers by age and BMI and watch premiums getting reasonable again

That's not the way health insurance works. The way it works it that the young and healthy are overcharged and that overcharge is given to the old and unhealthy.

Massachusetts may try it as well: https://masscare.org/

It'll be a very interesting experiment, if it works, other states will copy it. If it fails wealthy people will leave those states for places with lower taxes, and poorer people will move in to gain free health care.

There's a reason the most populous states (CA, NY, MA) are the ones trying it first, and it's not because it's cheaper.

Vermont tried it first, and it is tiny, and stopped it because it was unaffordable. I would say the correlation is with how Democrat a state is, not how populous it is. And while it is good for political campaign slogans, I highly doubt CA/NY/MA legislators actually vote it into law.

I can't help but read "massacre" when I see "masscare"...

As they say, naming things is harder than you'd think

>Massachusetts may try it as well: https://masscare.org/

Massachusetts has had 98% health care coverage for more than 15 years. (The only countries in the world with more than that are those, such as the UK, in which no membership card is needed for receiving care.)

Health care coverage with a deductible and copays is not at all similar to taxpayer funded healthcare such as that in the UK.

That has nothing to do with my point, which is that Massachusetts has 98% coverage.

Neither the UK's monolithic NHS that combines single-payer insurance and (more or less) 100% free on delivery with no membership card, nor Canada's single-payer insurance with no legal private alternative, is the norm internationally. Germany, Austria, Switzerland, and the Netherlands all have Obamacare-like systems with dozens of competing private insurance plans with premiums. 30% copay is the norm in France's three separate government insurance plans. Australia has single-payer insurance but people are heavily incentivized to move to private plans. Etc., etc.

Why would you want it nation wide?

Even if you “support it”, I’d much rather watch the implications from the various experiments across states. Then we can select the best option.

Personally, I’d like to see some states ban healthcare outright. Others have full coverage and everything in between. Then wait 10 years and we can see the results. I strongly suspect there would be states willing to do this.

Exactly.

US salaries for healthcare are the best on the planet, period.

The comparison (and to be fair, this is a very high level) paints an extremely clear picture:

United States $313,000

Germany $163,000

United Kingdom $138,000

France $108,000

Per: https://www.worldatlas.com/articles/countries-with-highest-p...

So yes, I absolutely want to see how many physicians stick around if you tell them "your salary will now be half and we're maxing our your workload". Alternatively, I want to see how long the State's finances last if they say "we'll pay the national market rate for your services and we're now maxing our your workload".

And even then I don't want 10 years, I want a generation or two. Even pre-COVID we had multiple surveys indicating that 60-70% of doctors would not recommend becoming a doctor. I want to see how that number changes as States run their experiments.

> "your salary will now be half and we're maxing our your workload"

should be fine if they pay their student loans no? isnt that the main reason the salaries are so high? cost of living + debt

Paying off 200K in debt with a 300K minimum salary is pretty trivial unless you immediately qualify for a 4 million dollar mortgage, buy a BMW, then get divorced six times after med school.

cost of living isnt the reason for high salaries in Medicines. Unlike tech, salaries in medicine increase as you go to rural and/or underserved areas. It is driven by supply/demand and quality of life in urban vs rural areas.

Sort of, the supply of physicians is artificially limited by the AMA - which dictates how many physicians there are. That keeps the cost of physicians nice and high.

100% agree but note that the AMA's limits are at a national level. So the [very high] base salaries are indeed driven by scarcity (as dictated by medical boards.) However the local scarcity is not driven by the AMA (note the salaries just get even higher! in remote locales as the local scarcity compounds atop national scarcity.)

> isnt that the main reason the salaries are so high?

It's because the NIH limits the amounts of medical residencies in the country, and to become a doctor with a license to practice, you must have completed residency somewhere. The amount of doctors in the US are kept at low numbers because of this.

I thought it was the AMA, but yeah I know about this and agree. This is the real problem

AMA lobbies but doesn't decide how residencies are funded.

I didn’t know that. Why does the NIH limit the number of residencies?

Imagine you were working in an industry where you got to decide the number of people you can let in behind you.

The option almost everyone picks is “no one”. Keep supply of your services low and increasing demand means more money for you.

Professional organizations have stronger incentives to increase their compensation through restricting supply instead of decreasing their compensation to help their customers.

The AMA is actually doing a great job at this recently compared to the ABA, where there have been too many lawyers graduating recently for insane salaries except at the top.

Medicare funds medical residency (not the NIH and not the AMA). The 1997 balanced budget act passed by congress limited the expansion of new medical residency training.

[0] https://www.npr.org/2018/03/09/592333771/severe-shortage-of-...

Thanks for the correction and source.

This will be a tough problem to solve. We could start by eliminating the AMA.

> want to see how many physicians stick around

Why would they bother to leave? Physician salaries might still very well be highest in the world.

I see this argument made often on HN. I would imagine if we compared software engineering salaries in these same countries you would see that similarly software engineers in the US are also "overpaid".

Software

United States of America $95,879

United Kingdom $68,664 = 72% USA

Germany $61,390 = 64% USA

France $47,617 = 50% USA

Medicine

United States of America $313,000

United Kingdom $138,000 = 44% USA

Germany $163,000 = 52% USA

France $108,000 = 35% USA

(I believe the software salaries I've sourced are somewhat conservative)

[0] https://www.codingame.com/work/blog/find-developers/average-...

Ban healthcare? Like make it illegal to receive care or are you saying have no concept of health insurance and everything is out of pocket?

Yep. I vehemently oppose federal Healthcare initiatives but im very receptive to state options.

presumably, you don't actually mean "ban healthcare" so much as some version of "prohibit government spending on healthcare" or somesuch?

I'm pretty sure there's actually no constituency for outlawing the practice of medicine.

Or maybe you're actually the misanthrope that I sometimes pretend to be?

This argument makes no sense. If you're really interested in "selecting the best option", there can always be a federal option complementing state "experiments".

> Personally, I’d like to see some states ban healthcare outright. Others have full coverage and everything in between. Then wait 10 years and we can see the results. I strongly suspect there would be states willing to do this.

This is the most HN comment I've ever seen

I'm not even sure what they mean by ban "healthcare" (insurance, doctors, hospitals?), and I can't decide if that makes me agree with you more or less.

I meant health insurance, but gonna just leave it lol

I figured, but with the "Most HN comment" meme and Poe's law providing context, it can be hard to be sure someone isn't suggesting something a bit more... extreme. :)

Lol first time my thoughts on banning health insurance is the less extreme option haha...

For reference, the idea is to optimize for public good. Banning insurance would drop fees dramatically because people would get less unnecessary work done. At the same time, hospitals and others would be willing to offer loans provided you could pay it off. This would drive down costs to the point even the poor can get some decent medical treatment. Any gaps can be made by non-profits, religious organizations and the like (similar to planned parenthood). Not perfect, but makes healthcare abundant and cheap.

> This would drive down costs to the point even the poor can get some decent medical treatment

Or we could just offer free healthcare without relying on unfettered capitalism to "work".

>unnecessary work

With capitalism as the driving force, anything unprofitable becomes unnecessary. Probably goes without saying, but focusing on profitability likely won't drive the best healthcare outcomes.

> At the same time, hospitals and others would be willing to offer loans provided you could pay it off.

I'm not sure we want to encourage people to go through loan terms while possibly fearing for their life, especially when the people advising them on their health options are associated with those offering the loan.

"We need to operate as soon as possible, you're at risk until we resolve this. Oh, here's the loan information if you choose to get a loan through the hospital. The terms aren't as favorable as some others might offer, so feel free to take your time and shop around. Oh, but don't forget that your time is limited. Let me know when you've secured funding and we'll schedule the operation."

> Why would you want it nation wide?

They didn't say they did, they said we're closer to having a legitimate discussion.

But to answer your question, if it's better, we might want it nationwide for similar reasons we have a national minimum wage and national child labor laws. For some things making sure there's a lower bound that everyone can rely on is a large part of the benefit, so inconsistent rules across the nation don't allow for a large portion of the benefit to be realized.

Whether this is one of those cases is something we'll hopefully get some more data on.

You need only peer across the globe. Take your pick between Germany, Singapore, Norway, etc.

I wonder if we could get an interstate cluster healthcare plan. NY, MA, CT, NJ joined together (ok RI, you too) certainly have the economic firepower and population numbers to get a good system going.

its would be interesting to see a deep-blue state coalition single payer system. that might pave the way to a national version of it.

Not to sounds hyperbolic, but we're moving farther and farther towards partitioning the country than we are towards M4A. The SC has just crossed the biggest line between liberals and conservatives for the last 50 years and signalled they're not done. The composition of the Senate and electoral college could put us a good 30+ years from being able to restore those rights. Best case scenario is both sides of the aisle double down on states' rights so liberals can have free choice and socialized medicine while the others can wait for maternal mortality rates to force their hands in a generation or two.

it appears that this bill does not actually deal with the funding mechanisms for single payer, which will undoubtedly be contentious. From the Campaign for New York Health:

> this legislation can be passed outside of the budget as a standalone bill - the #NYHealthAct is intentionally written to first pass on human rights principles - that care should be equitable and available to all. Then we pass the funding mechanisms in the following session - that is when NYHA becomes part of the budget battle) - begins implementation of systemic long-term change to guarantee universal, comprehensive, single-payer healthcare to everyone who lives or works in New York

from: https://www.nyhcampaign.org/

Seems a bit pointless to pass a feel good bill that will cost billions and ignore the whole money situation hoping to solve it.

Elections are coming up.

"Died in committee" I assume will be the final result, official in a couple weeks.

ha lol, one sponsor, in committee

yeah I don't consider this kind of thing news, but it did open a conversation that I wanted to have

maybe I'm misunderstanding but I see at least 4-5 cosponsors that are members of the health committee?

not saying I think this will come to pass necessarily but there's like 30 cosponsors listed and the NY State Senate is 63 members.

That is a lot of cosponsors, I was reading the page wrong

(Govtrack’s site and Congress houses have a slightly different format for showing sponsors and cosponsors together)

understandable, I didn't realize it had this many cosponsors and I live in NY.

If this is anything like the ACA then the vast majority of New Yorkers will end up paying twice for insurance. Once in taxes to subsidize the single-payer marketplace, and then again for their own employer-based insurance. Have to start somewhere though, I guess.

If doing something is going to make the situation worse, it is better to do nothing instead.

It may only appear to make things worse. Sometimes you have to take drastic measures, like amputating a limb, to make progress on saving people.

You seem to believe employees wouldn't be able to opt out of their own employer-based insurance. Why is that?

For the employee it doesn't matter. Either I keep my existing insurance or I opt out and take the state provided one, but I don't get any more money the money I'm saving the company.

Yeah, the penalty for ACA non-compliance is zero at this point, so I think they could just opt-out entirely without cost, right?

I looked at it last year in terms of whether I'd need to pay for COBRA to cover the tax penalty and... nope. You can retroactively opt into COBRA for 90 days after the fact (iirc, check this yourself before using), so you can job hop and then if you happen to smash every bone in your body during that one week then just sign up for retroactive coverage.

From the summary of the bill:

> Private insurance that duplicates benefits offered under New York Health could not be offered to New York residents.

---

My interpretation of that is that private insurance (which includes employer-based insurance) would be banned.

That's an incorrect interpretation. Private insurance would be restricted to cover things not already covered by the public insurance.

> The benefits will include comprehensive outpatient and inpatient medical care, long-term care, primary and preventive care, prescription drugs, laboratory tests, rehabilitative, dental, vision, hearing, etc. all benefits required by current state insurance law or provided by the state public employee package, Family Health Plus, Child Health Plus, Medicare, or Medicaid, and others added by the plan.

I'm struggling to understand what is not covered beyond that.

Nooo! Public option is not a half measure, it's a ~zero measure.

Single payer >>> public option. Public option is really easy to kill, just kneecap it any of a hundred ways, call it a failure, and then sell killing it as a tax break. It has the staying power of a cobweb on a car wheel. Failure is inevitable and it won't just be dead, it'll be held up for decades as proof that our government is uniquely incapable of doing insurance.

Contrast to single payer, which is hard to kill because people are yes paying a tax but also seeing a benefit and seeing a benefit that they didn't have before (healthcare doesn't go away if they lose employment). It doesn't suffer from adverse selection, it isn't an easy target for kneecapping, and it has a chance in hell of actually working.

I would advocate for Medicare-for-all but that isn't going to happen in my lifetime. So if states want to try their own single-payer systems then go for it. But I'm still going to grumble if I see (yet another) big number taken out of my paychecks for it.

How/why is failure inevitable?

>Contrast to single payer, which is hard to kill because people are yes paying a tax but also seeing a benefit and seeing a benefit that they didn't have before

Isn't that true for a public option as well?

No because it is a public option. Thus not everyone uses it.

There are UK employers who have offer health insurance as a benefit on top of the healthcare available from the NHS. There's not much point to it, but it is available.

I have such an arrangement and it's extremely useful.

Yeah, that'll be great for the state with one of if not the highest costs of doing business in an age of remote work: another payroll tax.

"Private insurance that duplicates benefits offered under New York Health could not be offered to New York residents. (Existing retiree coverage could be phased out and replaced with New York Health.)"

That is an important paragraph. If you want good public health care, you need to make sure the rich use it too. Canada does it by not allowing doctors to work in both the public and private systems. This law takes a different approach, instead barring the insurance companies from competing. Wonder if it will hold up in court.

Without this paragraph I don't think it could be a good system. With it, there's at least some hope.

Crazy healthcare costs are the result of government intervention back in the 30s, and I’m doubtful they will actually be able to lower overall costs. Single payer has the advantage of being able to negotiate the costs for a much larger volume, but my guess it won’t be enough to cover the cost of bureaucrats to administer it.

Still I’m all for them trying it, if it fails miserably and the “free” healthcare leads to never being able to see the doctor and costing more, then everyone else can stop trying to emulate it. If it succeeds and actually saves money and still provides good healthcare, then we might be able to try it at a larger scale.

The US pays vastly more to administer it's health care than any other OECD country. Your assertion that the cost of government bureaucracy should exceed the cost of private markets at this task is emphatically not backed by data.

A good place to check your assumptions on these kind of basic things is the OECD data. Healthcare is here:

USA 1.4% of GDP on governance of healthcare Germany 0.5% (competing public insurance schemes) UK 0.2% (single payer)

US style healthcare is an ideologically driven luxury.

Well maybe our bureaucrats are simply better at getting paid.

Still the healthcare issues being fixed with more government intervention is like someone breaking your leg then giving you crutches and saying “where would you be without me”.

It would be great if they could handling things already successfully resolved in other places, like Balance Billing https://en.wikipedia.org/wiki/Balance_billing#United_States

When I was with a Virginia employer, it was WYSIWYG on billing. In NY, you never know since there is the co-pay, and then there is the surprise 2nd bill that comes in the mail. It is a solved problem, not sure why such obvious solved problems cannot be implemented in NY.

Balance billing was banned federally. https://www.dfs.ny.gov/consumers/health_insurance/surprise_m...

Sort of. But if you read the article:

"""Consumers in New York are protected from surprise bills when treated by an out-of-network provider at a participating hospital or ambulatory surgical center in their health plan’s network. Additionally, consumers with health insurance coverage provided by an insurer or HMO are protected from surprise bills when a participating doctor refers them to a non-participating provider. Consumers in New York are also protected from bills for emergency services in hospitals, including inpatient care following emergency room treatment."""

Note that part of balance billing is from in network providers who are billing the difference, that doesnt seem to be covered in the above ban from what I'm reading.

Would this raise the tax rates for NYers?

It would be shocking if it didn’t

No, it wouldn't.

The European single-payer systems pay half what we do per-capita, factoring in private and public spending in both systems. The US system is wildly cost inefficient.

See the chart at https://data.oecd.org/healthres/health-spending.htm

Of course it'll raise tax rates. That money does come from somewhere. The real question is whether employers will raise salaries enough to compensate for the additional taxes, once they're no longer providing insurance as a benefit.

If I pay $10 in tax to save me $20 in costs, I'm not inclined to see that as a tax hike.

It’s still a tax hike, regardless of your rationalizing

Then a focus on tax rates instead of total cost is entirely disingenuous.

Not really, there are people who get great health care for free from their employer, and others who get a greatly discounted rate. Their employers will not necessarily savings with their employees.

The result for these employees could be more taxes for the same or worse care they’re already receiving.

In aggregate I believe it’s the right move but let’s not act like everyone wins here.

> Not really, there are people who get great health care for free from their employer, and others are a greatly discounted rate, who will not necessarily share savings with their employees.

Then require that savings be shared.

Make it a legal requirement that any company that has employer-provided healthcare must rebate employees the premium costs if they opt-out.

That makes no sense, salaries would simply be adjusted to compensate. The kind of bureaucracy you’re proposing is why things are already so complicated to begin with.

> That makes no sense, salaries would simply be adjusted to compensate.

If you cut the salaries of employees who opt-out, but not those who don't, you'd be in very clear violation of the law I'm suggesting.

No, what I’m saying is that they wouldn’t offer an alternative to the state run health care, as why would they anymore? No incentive.

I'm not seeing the downside.

The downside is that you could be paying more taxes for something that you already had.

Then perhaps it's time to unlink employment and health care coverage entirely.

No disagreement here.

> Not really, there are people who get great health care for free from their employer

It is not 'for free' it is part of your compensation! It's like saying your employer pays 6.2% + 1.45% in SS/Medicaid taxes 'for free'. That is part of your compensation.

I meant free in that you don’t pay a premium, but fair point.

> It’s still a tax hike, regardless of your rationalizing

You're already paying for health care coverage via monthly/annual premiums and via reduced salaries where your employer's portion is part of the 'total compensation' you get (but doesn't show up in your pay check).

Even if the amount at the end stays exactly the same it may be an improvement because (a) there are no "in network" worries about going to the "wrong" hospital or getting the "wrong" doctor", and (b) it is universal coverage so (i) you may not have to worry about losing your job and losing coverage as well as (ii) you can change jobs and have the same (universal) coverage.

That assumes you get the cost saving. If my company stopped paying for my insurance benefit and instead gave that money to me directly, and then I bought the cheapest plan I could find on the insurance exchange ... I'd be paying more, not less. By a fair amount.

That seems readily fixable; make it a legal requirement that companies that provide employer-provided healthcare pay the premium to the employee if they opt out.

In my case the premium wouldn't even come close to the marketplace cost. I'd be losing overall.

https://www.peoplekeep.com/blog/which-health-insurance-costs...

> Nationally, the analysis found that individual ACA Marketplace premiums are 10 percent lower than the average employer-sponsored insurance premium, after the adjustments.

(Which makes sense; it's a very large risk group.)

Okay, then congratulate my employer for beating the odds, I guess.

Numbers, please. This kind of claim is just mythology unless you have numbers to back it up.

Is this because your employer is paying part of the cost for the plan?

>The real question is whether employers will raise salaries enough to compensate for the additional taxes, once they're no longer providing insurance as a benefit.

I don't think that's even a question. The answer is no, they won't.

> The real question is whether employers will raise salaries enough to compensate for the additional taxes, once they're no longer providing insurance as a benefit.

Spoiler: they won’t. They’ll spin not having to pay a premium as a pay raise.

I think the idea that anything that worked in Europe would work here as well as there without inherent corruption and rent seeking is laughable.

The idea that the US is uniquely corrupt and rent-seek-y seems laughable.

There's no corruption in Italy? Eastern Europe?

The amount paid per capita and whether you would pay more taxes are not exclusive things.

I’m not sure why people keep bringing up Europe - the USA is not Europe. For one doctors are paid more in the USA compared to Europe, medicine is more expensive here, more of the R and D originates here, etc

Maybe good question to ask is what makes it more expensive? Is it bloated administration and insurance system? Or is there some fundamental other difference?

One reason is it is expensive to fund the research and testing and so the companies need to recoup that cost. They cannot in Europe and Canada due to price controls which means people in the US offset the cost. The US is basically subsidizing other Western countries.

^This guy gets it.

Also, in nearly every parliamentary system the state's ability to quickly invalidate patents by an act of parliament gives them even more leverage in the negotiations with drug companies.

A lot of that R&D is already funded with our taxes via the NIH.

A significant portion is not. Clinical trials are unbelievably expensive, see https://www.science.org/content/blog-post/drugs-come-compreh....

(actual data which undermines the political rhetoric around this topic)

"Critics of drug price regulation argue that free market pricing strategies and higher prices in the United States are instrumental to innovation. One might therefore expect the United States to be the most innovative given that it is the only country with a predominantly unregulated pharmaceutical market. However, US pharmaceutical innovation appeared to be roughly proportional to its national wealth and prescription drug spending. Our data suggest that the United States is important but not disproportionate in its contribution to pharmaceutical innovation. Interestingly, some countries with direct price control, profit control, or reference drug pricing appeared to innovate proportionally more than their contribution to the global GDP or prescription drug spending."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866602/

> The amount paid per capita and whether you would pay more taxes are not exclusive things.

It'd be a deal even if it costs exactly the same.

The better question is whether NYers will pay more or less under this plan, not whether that payment is a tax or a premium.

i think the original question was better

Summary says it includes a "payroll assessment, similar to the Medicare tax"

One thing I don't understand is how you can make healthcare "equal" in the sense that it will stand up to court challenges in the U.S.

Free speech is a self-service right, so the government can just step out of the way and everything is fine. But healthcare requires the government to do a lot. Not doing something equally (like stepping out of the way of free speech) is easier than doing something (like healthcare) equally.

The SC is trying its best to devolve all powers to the states. They can't have it one way for a contentious issue and then be hypocrites for anything else.

Who’s gonna stop them?

Perhaps 'restore' would be a better choice of word.

50% of health resources are used in the final 5 years of life.

The young should not pay for the healthcare of the elderly. Society should be apportioned into different age categories, and funded separately, with a 'base' tier for all citizens and legal residents, and a higher tier for those with private or employer insurance.

Who funds the more expensive tiers?

> The young should not pay for the healthcare of the elderly.

Why?

I think funding the elderly is a lofty goal, but I don't see a good intellectual argument for FORCING our children to pay for our healthcare. You shouldn't view your child (nor your neighbor's child) as your own personal piggy-bank to extract from when you get ill.

IMO our goal should be to hand down resources from parent to child, not the opposite direction.

If I made this story a bit more personal and wrote ("I am too ill to work anymore, so I drove to my son's house and took $200 off his counter to buy my medication) HN would be reacting with outrage.

What alternative do you propose? Suicide booths?

Literally any other option than telling our children they must involuntarily pay, like they're our own personal piggy bank. Saving, asking nicely, charity, debt/mortgage the house, and other forms of voluntary transactions sound acceptable. If you truly have no other options then you can make the moral judgement whether you want to involuntarily take from our children because you think the investment on yourself is worth more than the investment on the youth.

I don't understand your argument.

You are helping others & others help you. What's the problem?

> If I made this story a bit more personal and wrote ("I am too ill to work anymore, so I drove to my son's house and took $200 off his counter to buy my medication) HN would be reacting with outrage.

How about making the story more fitting the reality here: You drive to your sons house and ask him to help you with your health bill and he helps you because...why wouldn't he?

>You drive to your sons house and ask him to help you with your health bill and he helps you because...why wouldn't he?

Asking is fine. Telling them they must is not. If the mechanism for payment from the youth to the elderly is voluntary I have no problem with it.

It kinda is voluntary. If you don't like it, you can leave the country which wants you to pay.

I don't get why you have a problem with that. It sounds to me like some anti-social behaviour pattern. Don't you pay for taxes or Government services too? This is how a civilized society works. The attitude you display here has become a bad joke when people talk about the US health system. You must be aware of that.

What do you expect people to do which can't afford to pay their health bills because they've been unlucky or something like that? Are they supposed to just die?

> It kinda is voluntary. If you don't like it, you can leave the country which wants you to pay.

Voluntary would be staying where you are and still not being forced to pay. When a mugger presents their victim with a choice like "your money or your life" they're not paying voluntarily just because there was another option. You don't have the right to evict people from their homes any more than you have the right to take their money.

> It sounds to me like some anti-social behaviour pattern.

The attempt to normalize theft is the only "anti-social behaviour pattern" here.

The funny thing here is that your obviously anti-social behaviour only works in a society where being anti-social has been normalized. You'd be dead in a social society because as a lone, greedy individual, you're weaker than a group where the strong care for the weak.

But even you must be aware that your model is coming to an end. The anti-social aspects of it have become a topic. Something which hasn't been the case in the past decades because the downsides of this model became so obvious.

You are part of a finally dying thought system and the parts you didn't answer to speak for themselves.

You're either trolling or completely clueless. I suspect the former is more likely but I'll try to give you the benefit of the doubt.

> You'd be dead in a social society because as a lone, greedy individual …

You're obviously reading way more into my comment than I actually wrote, which says more about you than me. I am 100% in support of groups working together voluntarily and looking out for each other. The system you advocated for is not that, and opposing it does not make one "lone" or "greedy".

> … you're weaker than a group where the strong care for the weak.

Imposing a "choice" of compulsory payments or eviction is not the strong caring for the weak, but rather the strong preying upon the weak.

> … the parts you didn't answer to speak for themselves.

I didn't address the rest of your prior comment because it wasn't worth a response. But since you insist:

> Don't you pay for taxes or Government services too? This is how a civilized society works.

Civilized society persists despite taxes, not because of them. Theft is not civilized, and treating it as legitimate is corrosive to any civilized society.

> What do you expect people to do which can't afford to pay their health bills because they've been unlucky or something like that? Are they supposed to just die?

Obviously they aren't supposed to just die. That question was not asked in good faith. Taking other people's stuff isn't the answer either; the products of their labor are not for you to spend. People are expected work to provide for themselves and to plan ahead for the future, setting aside a portion of the surplus during good times to sustain them through the bad times. Working together with others makes this much easier but it is first and foremost an individual responsibility. For the truly unlucky cases there is plenty of honest, actually-voluntary charity to go around.

> You're either trolling or completely clueless. I suspect the former is more likely but I'll try to give you the benefit of the doubt.

Wrote the person who just repeated some random Ayn Rand bull. Seriously? You are accusing me of trolling? With that material? :D

> I am 100% in support of groups working together voluntarily and looking out for each other. The system you advocated for is not that, and opposing it does not make one "lone" or "greedy".

I wonder if you are really so naive or if you got so used to repeating that as an excuse. If we'd live in a society where voluntary donations would suffice, we'd not need laws or regulations.

> Imposing a "choice" of compulsory payments or eviction is not the strong caring for the weak, but rather the strong preying upon the weak.

You must be from the US where there are two parties and you can buy into a political position form the national to county level. In other parts of the world, there is still democracy and yes, none of those are perfect but if you consider any serious statistics on where people are most happy, it's those (really) democratic countries with a wide ranging social system [0]. So please...spare me that Atlas Shrugged Fan Fiction...

> Civilized society persists despite taxes, not because of them. Theft is not civilized, and treating it as legitimate is corrosive to any civilized society.

Oh so taxes are theft now? And you accuse me of unworthy comments? This is hilarious.

> Obviously they aren't supposed to just die. That question was not asked in good faith.

Nothing...seriously not a single sentence you've issued here is something someone with a healthy moral compass would consider "in good faith". Your answer here is literally: they should have a go fund me to save their lifes...I mean...lol...I don't even know how to answer to so much crap. I really hope I'm talking to a child because I have worked in some really terrible Fortue companies and I haven't met anyone who'd fall so deep down the "Wolf of Wallstreet"-LARP.

Edit: ok, I've had to look you up and it wasn't that hard because you 'muricans have no sense of data protection (or any laws for that) and hell, where do you even get those ideas from? You are some random tech guy and an aerospace company with a career which didn't even touch areas where this kind of talk would be something to come close to. Who the hell do you think you are? Some random financial crisis would throw you onto the street. Who do you think will make a go fund me for you? Your colleagues? You probably even vote for the red party...I don't even...

[0] https://www.forbes.com/sites/laurabegleybloom/2022/03/18/ran...

>Who the hell do you think you are? Some random financial crisis would throw you onto the street.

And here the true colors emerge. You pretend to care about supporting others, but you take the first opportunity to denigrate someone for your perception that they are not rich enough to weather a storm.

No one here has shit-talked you because of your finances. No one here has lambasted you because of your occupation or station in life. No one here has accused you of wanting compulsory social securities, or not wanting them, on account of your occupation or finances.

>You are some random tech guy and an aerospace company with a career which didn't even touch areas where this kind of talk would be something to come close to

And what? Does one have to have special qualifications to comment on the topic of how their own earnings are to be spent?

>You probably even vote for the red party

You go on about democratic ideals, yet you criticize someone for engaging their civil liberties to vote in that system?

Disgusting.

> And here the true colors emerge. You pretend to care about supporting others, but you take the first opportunity to denigrate someone for your perception that they are not rich enough to weather a storm.

No, that's what you want to read because what I actually wrote would hurt your world view too much. That's why I repeat it again: THE SYSTEM AND IDEOLOGY YOU LOVE WOULD CRUSH YOU.

> No one here has shit-talked you because of your finances...[yahda no you yahda]

So now that I used your own world view on yourself, you're hurt so much that you not only drop the whole topic but roll on the floor crying? Already? Look at you how desperately you try to twist my simple words so it somehow might make you look better. Look how weak you are. Your personal crisis in your own world didn't even start and you're broken already. Look how easy it was. And you think you can survive in this evil and anti-social society you cherish so much if you hit a true bump?

Pathetic.

Luckily in true democratic and social systems there would even be a space for a broken and weak person like you who had a bad luck, lost his job or health. A whole nation would come to help you out with everyone giving a bit of their wealth. Lucky for you, you can move to one of those countries since the one you're in now will kick your ass if you fall and if you open your eyes on your way home in a few hours, you might see those victims of your greedy and selfish vision. Victims without gofundmes who will die in poverty without you giving a damn. Even though it could easily be you.

Think about it.

>you're hurt so much that you not only drop the whole topic but roll on the floor crying?

>Look how weak you are.

>Your personal crisis in your own world didn't even start and you're broken already. Look how easy it was.

>his evil and anti-social society you cherish so much

>a broken and weak person like you

Lol and I'm supposed to be the "anti-social" one, after you've written this drivel?

I've survived in a number of nations and varying societies, from US to Syria to Paraguay. I've survived homelessness, war, unemployment, and other challenges without turning to involuntarily funded social security. I've voluntarily spent tens of thousands to support loved ones. I'm trying to live the voluntary life I preach, or at least move closer to it; of course both you and I are flawed.

I'm not sure what the full range of systems are under which I would survive, or at least not be 'CRUSH'ed under. But I do know I will survive just fine without reading further your anti-social ramblings. Good day.

It's quite funny that you are seriously unaware how much information there is about you on the internet. Freely available.

But I guess you need to lie to yourself to be able to spread that kind of Ayn Rand LARP cringe material.

Bye.

> I am too ill to work anymore, so I drove to my son's house and took $200 off his counter to buy my medication

Maybe it is because we come from different cultures, but I see absolutely nothing wrong with this. In fact, I recently paid for my parent's hospital bills and did it happily.

My country doesn't have universal healthcare, but I'll be happy if we did. At the end of the day, we live in a society, and one of the imperfections is that we end up paying for things we don't like regardless of our opinions. I think healthcare should be a priority...

>In fact, I recently paid for my parent's hospital bills and did it happily.

Yes and I recently paid thousands of dollars for my wife's hospital bill, would you like a cookie? That's how it's supposed to work: you voluntarily decide to help your loved ones and the payment is made.

How it isn't supposed to work is that the elderly make a moral judgement that the youth are less deserving of investment than themselves, and involuntarily they extract that money from the youth without their consent. I have no problem with a society where you voluntarily pay your parent's hospital bill, in fact you can do that in most any country already. Congratulations, your goal is already achieved.

>we end up paying for things we don't like regardless of our opinions

In this case you seem to mean we are made to pay for others without our consent.

>I think healthcare should be a priority..

Maybe I think hookers should be a priority; sex is correlated with good health. You wouldn't mind if I took a couple hundred from you for my health would you?

> Maybe I think hookers should be a priority; sex is correlated with good health. You wouldn't mind if I took a couple hundred from you for my health would you?

Well, different priorities, and that’s fine.

But, let’s assume in a democracy, the majority of people decide to vote for free hookers and blow for everyone, why not :)

>But, let’s assume in a democracy, the majority of people decide to vote for free hookers and blow for everyone, why not :)

Majority of _what_ people. The majority of people within my square mile? This continent? The majority of people in my house? I merely reduce down 'democracy' to its logical smallest element, the individual. I vote what I will spend my earnings on, and as the only voter my vote wins. Of course, my vote has no effect on obligation of others, as they are not part of my own 'democracy.'

Very few people want a pure democracy. Pure democracy is 5 people in a house, and 4 vote to beat the shit out of the fifth. Pure democracy is when 60% whites vote to make blacks their slaves. Pure democracy is voting to intern the Japanese in camps.

Voting is fine, involuntary extraction of resources from others is not.

> The young should not pay for the healthcare of the elderly.

The same way responsible drivers should not pay for reckless ones? Or responsible homeowners shouldn't pay for reckless ones?

The whole idea of insurance is to distribute the costs so that no one has to bear long tail costs alone...

Private auto and homeowners insurance are not price-insensitive, despite being mandatory (former case, by mandate, latter case, in practice for mortgaged property). If insurance companies paid out indiscriminately to the reckless; i.e. failed to manage their risk; then their premiums would get too high and they would lose their average customers.

There is no analogue for taxpayer-funded healthcare. There is no practical upper bound on the cost. The over-users will not run out of other people's money. Unless, of course, there are death panels; everyone loves death panels.

Long tail costs are things like freak car accidents, hail, etc. Reckless drivers should and are charged more because their costs are higher as a result of their own choices. Obese smokers should be charged more than healthy people but they're not because ACA says you can't discriminate based on pre-existing conditions. That means healthy people end up subsidizing lung cancer treatment, heart disease treatment, insulin, etc. for fat people.

edit: correction, ACA permits charging tobacco users extra. But not, for example, weed users.

Older people do pay more for healthcare insurance…

Yes, because age (like smoking) is one of the few factors ACA Marketplace plans can take into consideration. But healthy older people pay the same premiums as unhealthy older people, which means one of these two groups is being overcharged. Moreover, it means that there is less incentive (not none, but less) to make an effort to end up in the first group as it won't affect your health insurance costs.

I absolutely agree with charging people with poor lifestyle choices more for their healthcare. They cost more, so they should pay more.

> The same way responsible drivers should not pay for reckless ones? Or responsible homeowners shouldn't pay for reckless ones?

Yes, exactly. Reckless drivers and reckless homeowners should pay higher premiums, as their insurance covers a higher risk (a priori expected cost) compared to responsible drivers and responsible homeowners.

> The whole idea of insurance is to distribute the costs so that no one has to bear long tail costs alone...

The "whole idea of insurance" from the buyer's perspective is to pay a fixed premium instead of carrying risk. The value of the service, and thus the premium one is willing to pay, is determined by the risk being mitigated for each individual customer. The existence of "risk pools" is important for the insurance provider's cash flow, but a mere implementation detail to the customer. Insurance is not a subsidy or charity; if you and others like yourself are expected to cost more on average than some other group, you should expect to pay more. In a competitive insurance market those with higher risks will pay higher premiums; a company that attempted to charge everyone a flat rate would find itself either bankrupt or incapable of competing on premiums for any but the most expensive (highest-risk) customers.

Anyone who hopes to someday be elderly should pay for the healthcare of the elderly.

I mean the young get kicked out of their commercial plans at age 65. So in a way they don't pay for it at the commercial level.

So what do we do with the sick and poor elderly folks? It provides a benefit for the younger as well in that junior doesn't have to worry about grandma dying of an untreated illness

> The young should not pay for the healthcare of the elderly.

I take an alternative view. When you're young, the payments you make into Medicare taxes are to take care of you later when you need it. A long-term HSA of sorts.

The original Obamacare came from the republican state experiment (the guy also went up to compete as potus as well). Experiment is good. But can you accommodate difference on lower level, so it is not one size fit it all.

Having said that by and large USA as a whole is a experiment of non-single payer.

I'm skeptical, but I'd like to see it pass. Such a debate in this country and it would act as an experiment. It would probably take a while for the consequences (good and bad, as I don't believe it would be purely one or the other) to become apparent.

One of the arguments for the federal system is that states do get to experiment and the ones that work go national.

They don't even have to make it single payer if they just say- no one is allowed to charge any patient more than they charge Medicare. You get the pricing power without forcing everyone into a state run plan.

The problem here is that you are going to get regulatory capture by the healthcare unions. So we'll get worse service at higher cost, not to mention incredible fraud

The country is run by the rich, and this will only pass if its good for the rich. Lets hope its good for the rich and the not-rich alike.

If only we can get the other 48 states to have a single payer health plan initiative or adopt a nationalized single payer health care system.

Health care should not be limited to just living in CA or NY or the rich.

side note: this site for tracking bills at the state level is kind of nice. Wish other states had this. This is what I have to deal with in TX

https://capitol.texas.gov/MnuLegislation.aspx

I wish all advocates for single payer systems could experience the Veterans Health Affairs (plus or minus the "Community Care" system) just to see what it they are in for. Give it a trial period of 2 years. Have fun.

There's too many jobs at stake for existing health insurers. This will go exactly nowhere.

I pay 100k+ in taxes, if this happens I'll be actually happy even more.

https://www.youtube.com/watch?v=kBsNvGyfM8Y

Any chance whatsoever they’re going to actually reimburse doctors for their massive school loans, while forcing them (“no network restrictions”) to work for this insurance plan? Especially if it’s anything like Medicaid, and reimburses physicians and hospitals -below cost-.

If we go by data, the US healthcare system is the most expensive (not arguable) and is not even in the top 5 among developed countries in the most important measures. These kind of experiments are welcome (if they come to pass). People deserve better for what they pay currently.

one of these references is from an US insurance company who you would think would be biased for US healthcare

https://www.cignaglobal.com/blog/healthcare/top-10-countries...

https://www.washingtonpost.com/world/2021/08/05/global-healt...

https://www.internationalinsurance.com/health/systems/

It's not rocket science, plenty of other countries manage to provide healthcare.

Just remove the age limit on Medicare.

But won't you think of the administrators at all of these private health insurers that would be out of their cushy jobs? I consulted for a "non-profit" Blue Cross Blue Shield franchise 15 years ago. It was rampant with nepotism and outright incompetence. A good chunk of our health-care "system" is just a giant jobs program.

> A good chunk of our health-care "system" is just a giant jobs program.

Yes, and government systems are peak efficiency without the slightest semblance of a jobs program.

I really want the government deciding what it considers "covered". Didn't get your Vaccine? Too bad, Democrats voted they won't cover your health care costs of a hospital visit. Unprotected Sex? Too bad, Republicans decided they won't cover your Plan B the next day. Your health choices are your business. Both sides have an agenda they will leverage and hold you hostage with.

Leave the government out of healthcare. They can't get make a functional driver license system, or a post office that doesn't dump billions of tons of C02 into the atmosphere delivering spam while being open between 11a-4pm, or run an airline security service like the TSA that actually stops threats and doesn't take away your Grandma's nail trimmers.

The private sector also established they will value profit above all else like pre-existing conditions they won’t cover, what’s in vs. out of network, who I need approval before I go see a specialist, limits on overall coverage, an ambulance ride that costs more than a first class plane ticket.

I want a system that measures outcomes that doesn’t sap double digit GDP, but the incentives are not structured in a way for success in this country (private or public).

Cue the Republican challenge arguing the state has exceeded its authority and this is a Federal issue (just like how Ajit Pai removed net neutrality saying it wasn't a Federal issue but then turned around and challenged California's net neutrality as being within the FCC's authority).

As for the NY bill, I'll be interested to see what this looks like. There are many variations on single-payer. For example, the NHS in the UK has many medical professionals (including primary care physicians) as government employees. In Australia, Medicare works by government rebate.

The other aspect will be how this will impact coverage out-of-state, employment coverage and employment insurance premiums.

You see many reactionaries argue "but it will raise taxes!". Welll... yes and no. You're already paying for your employer health insurance. This just shifts that cost to the government (sort of) but now health insurance isn't tied to employment.

Data point of n=1: I think this effort by NY is exactly where the experiment of single-payer health care in the United States should occur, as per the 10th Amendment. According to Third Way[1], (which advocates for federal-level universal healthcare), three other states which have tried single-payer health care have ended up discontinuing their programs: Colorado, Massachusetts, and Vermont. Perhaps New York has identified where those states have failed and its proposal will address those shortcomings.

[1] https://www.thirdway.org/report/single-payer-health-care-a-t...

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