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Comment by lotsofpulp | Hacker News Reader

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.

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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...

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

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