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Comment by CSMastermind | Hacker News Reader

What's to stop your local city government from increasing taxes to hire a doctor and provide them with a building and staff in order to provide medical services to locals residents?

It seems to me that the problem is that everyone wants a federal solution to healthcare and the United States is generally structured to limit federal power.

Fire departments are funded locally generally speaking, it didn't take a federal mandate to create them. If you think medical services should be provided to people as a civic service, go convince your local government to do it.

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https://www.actuary.org/sites/default/files/pdf/health/pool_... ("For a risk pool to remain viable, it must be of sufficient size and comprised of a broad cross section of risks.")

There are US states more populous than some European countries. Maybe a city can’t do it, but plenty of states could. It’s just damn expensive to try.

Reading your comment, I had the thought "I wonder if California's done it?" Turns out they've tried it 10 times. I'd imagine there's a lot of money being thrown against the initiative by for-profit insurance companies, which is an industry with a lot of cash to buy laws.

https://stateofreform.com/featured/2023/05/california-seeks-...

That reads like they've tried to try it 9 or 10 times. They haven't even gotten to the point of finding out what all might turn out differently in a US state than in an EU country surrounded by other EU countries, all with roughly similar approaches to public health care.

I work in public health at a state government, in a western state. The biggest hurdle I see is that America has freedom of movement and residency. If my state creates truly affordable health care, we will of course have refugees from conservative states coming here for medical care.

We'll probably end up with a public option of some kind that will somewhat function like health insurance but who knows.

This is an interesting point. And perhaps worse yet, high quality doctors will have the freedom to move out of your state.

I'm an American living and Germany and sadly, my GP who is also a personal friend of mine, will be shutting down their practice at the end of the year because their small practice simply isn't financially sustainable. They will instead start treating the prison population, which apparently pays more / is more consistent.

So I can also imagine how doctors in your state would feel if suddenly their rates are dramatically capped by the state.

I'm not aware of any public health care systems where medical care services are as expensive as in the United States, but perhaps it's possible to maintain relatively similar doctor pay as currently exists AND provide socialized health care benefits. I really don't know enough about this topic and the financials of American (non-public) health insurance companies to comment accurately on whether that would be feasible.

There is no chance that the state would cap rates, I'm not sure they even could. The real pull would be trying to expand Medicaid, which is free,creating a single payer system and raising taxes, or creating public health insurance, or some combination of both.

The public option would be the best in a vacuum, but if its truly affordable, we will still attract uninsured and under-insured people who come here when they get sick.

Prices could probably drop if the market was saturated with doctors. And the best way to do that would be eliminating medical-school debt.

I thought the limited number of residencies was the real bottleneck?

Both

Both are important. The high cost of medical school means people are only going to try and go for the specialties that pay the most (surgery, oncology, radiology, etc) leaving a shortage of Drs in other specialties like primary care/family medicine.

Primary care reimbursement rates also need to be raised and we need more preventative treatments that insurance is required to pay for.

I'm comparing to the best public healthcare system I'm personally familiar with (Germany) and saying:

* Medical-school debt is not a thing here. * Prices are low. * I know doctors who can't make a sustainable income to keep their small practices open.

Somewhat puzzlingly, for a handful of services, there can a medium length delay in getting an appointment because of how busy the doctors are.

This is definitely all much better than the situation is in Canada, where the typical person struggled even to get a GP, and friends with cancer would be forced to wait a life-imperiling year to get a routine scan that be the difference between life and death.

This is a challenge. It would be unconstitutional to out right ban individuals from getting the benefits, but maybe a waiting period would be constitutional(i.e. must be a resident for 1 year to sign up).

They haven’t actually tried it. The last time it was yanked from being voted on because politicians make promises to get elected and are then told by their donors not to dip into their profit pools.

But in many ways California already has it if you qualify based on income (Medi-Cal / Medicaid).

It actually works well which is why it won’t be made available to everyone. Stock prices and profit margins would drop too much.

If you want consumers that spend more money on your products, you need consumers with more money. To some degree, an inefficient healthcare system stands in the way of every other industry's profits. A suitably ambitious middle manager at a large company could probably make a dent. A CEO of such a company might actually capture some of that inefficiency.

The problem with doing it at the state level is that then all the sick will move to that state. Which won’t work from a risk pool perspective

It would seem unlikely that all sick people would move just for one perk. Most people do not take moving as a light decision.

Also most people that actually do move would likely have jobs with taxable wages that helps to subsidize things.

The real risk population is maybe the homeless sick that migrate. But those tend to be in a different category entirely (e.g mental illness, addiction, trafficking etc.)

Well sharts, most people don’t take dying too lightly either. Free care for the gravely infirm would be, to a point, the only perk that mattered at the exclusion of all others. Likewise with the possibility of total bankruptcy.

This problems is mostly solved for in state vs out of state tuition. Just institute 12-15 month waiting period or 3 months waiting period with full time job.

Mainly, that one city or state doing it will likely cause an influx of sicker people. You can't require a visa to come to, say, Austin TX, and "only to residents who've lived here longer than x" would raise equal protection constitutional issues.

(This is the same reason the ACA had the individual mandate, and why said mandate's striking down is likely to result in the ACA's failure or needing significant amending soon.)

> "only to residents who've lived here longer than x" would raise equal protection constitutional issues

States seem to apply residency consideration all the time to college tuition and taxes, among others. Why would equal protection be an issue here?

Austin, TX can't implement this on its own without state support, but cities don't have any federal constitutional rights apart from their containing states, so that's too bad

> States seem to apply residency consideration all the time to college tuition and taxes, among others. Why would equal protection be an issue here?

Because you're either going to have to pick some fairly short period of time - a year or less - which won't be that much of an obstacle to folks seeking healthcare (especially if private healthcare remains available in that interim period), or you'll run afoul of Zobel v. Williams if you try to make a permanent or long-lived distinction.

Yes, that is a trade-off.

You structure it as paying into a plan. For each year lived in the state you get 20% coverage (upto 5 years) which would smooth out the cost and provide fairness to poorer local residents.

Do you count the influx of homeless as residents? These people absolutely need healthcare, but they are a resource drain that can move in suddenly, unpredictably, and overwhelm a local solution with static resources.

Then you get a situation where the wealthy, even (and sometimes especially) the diehard leftists who voted for the situation, turn up their nose at what’s shown up in their backyard, and fuck off from California to Colorado or Texas. This reduces the tax resource pool, stressing the residents and businesses that can’t afford to leave further. This creates resentment.

Coupled with the overly dramatic and personal shitshow that is local politics, frankly I see local initiatives as a fantastic way to fail tens of thousands of times.

Fixes have to take place at least at the state level, and even that is less than ideal, because expenses have to be spread out (especially in regards to the wealthiest 1% that pay a huge chunk of income tax, and are not equally distributed across local towns) without creating an attractive hotspots for tax resource competition.

Except the only demographic of net in-flow _moving to California_ are those in the top 5% or so.

https://www.latimes.com/politics/la-pol-sac-skelton-income-t...

Note: this article is from 2019, which is obviously pre-Covid. I still think it’s too early to predict any trend on post-Covid migrations (which would really be captured and 2022-2023 and 2023-2024, assuming you started planning to leave mid-pandemic 2021-2022)

California had its largest tax surplus in the history of a state ever the 2022 fiscal year.

FYI, unless they fix their tax system, they are currently headed towards a (last I checked) 30+ billion dollar deficit this year. They also recently raised taxes on income over (I think) $1 million again last year, and I believe plan to continue to do so.

Also for a more up to date perspective on migration and money: https://calmatters.org/commentary/2022/08/california-is-leak...

https://www.sfchronicle.com/sf/article/San-Francisco-migrati...

Regardless, this still supports my point that state level healthcare while far more durable than local gov, still can’t compare to national level stability.

In the large, the issue is taxes are too low to support current spending. Only the federal government can run a sustained deficit. Republicans aggressively take advantage of this to cut taxes while disingenuously complaining about debt.

There really isn’t anything that constitutionally prevents the federal government from establishing universal healthcare. See Medicare and Medicaid.

I don't know about other states, but my state Tennessee and its counties do just this. I'd be willing to bet it's more common than not across the US. https://www.tn.gov/health/health-program-areas/localdepartme...

San Francisco started doing something like this in 2007: https://en.m.wikipedia.org/wiki/Healthy_San_Francisco

Hospitals and public health systems owned and operated by city and county governments are not actually unusual in the US. They're fairly common.

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