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Comment by ldayley | Hacker News Reader

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.

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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.

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...

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 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.

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

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.

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).

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...

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.

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.

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

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!

Retirees usually use Medicare.

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.

>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.

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

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

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.

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-...

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

> "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

> 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?

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.

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.

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.

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.)

> 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.

> 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.

> 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."

> 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.

> 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.

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".

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.

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

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.

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.

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

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.

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