
Healthy California Act: proposal to make findings about single-payer healthcare - old-gregg
http://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB562
======
df3
A well-executed single-payer system would make California even more attractive
for entrepreneurship and increase labor mobility for everyone. Life would be
much easier if we could start companies or switch jobs without worrying about
healthcare.

~~~
jbhatab
Here's the only thing I'm confused about. Do we have examples of the
government running a service better than the private sector?

I'm not 100% on this, but it seems all of the best aspects of American
services come from competition and letting capitalism thrive.

Would love a counter opinion.

~~~
enraged_camel
You would do well to start questioning the idea that the private sector does
anything "better". After all, it was them that gave us Enron, Deepwater
Horizon, and most recently, the subprime mortgage crisis, which brought the
entire world economy to its knees. Those are only a few examples that spring
to mind.

In addition, comparing the government with the private sector is pretty silly.
They have different goals. Private companies try to maximize profit, even if
it comes with massive externalities (which, barring regulations, they happily
pass on to others). Governments aim to serve their citizens, even if it comes
at the expense of efficiency. This means that any given problem will be
handled very differently by the private sector compared to the government. The
route we pick really depends on our priorities as a society.

~~~
refurb
_After all, it was them that gave us Enron, Deepwater Horizon, and most
recently, the subprime mortgage crisis, which brought the entire world economy
to its knees._

That's a pretty poor argument if you line it up against gov't waste,
incompetence and corruption.

~~~
enraged_camel
Can you provide any arguments (or, even better, empirical evidence) as to why
the government has more waste, incompetence and corruption than the private
sector?

~~~
refurb
I'm not arguing one is better than the other. Just that both system are run by
humans so I wouldn't say you'd have less corruption or waste in one or the
other.

~~~
toomuchtodo
I can vote out government representatives; I cannot vote out unregulated
companies doing damage in a marketplace.

Government provided services provide the opportunity for total transparency;
this is not the case in the private sector.

EDIT: @refurb: You're confusing a free market with what the United States has.
A free market it ain't (especially regarding healthcare).

~~~
refurb
In a free market you can chose to go with another company.

~~~
FullMtlAlcoholc
Provide me with an example of a fully functioning free market completely
devoid if any government regulation or involvement?

If one doesn't exist, I wouldn't like our system to move into that direction
based upon wild speculation and pure theory. The implicit assumption in free
market models is that people are rational agents, when all research shows that
people are highly irrational.

Wouldn't you like see evidence of how a free market would function on the
scale of the United States? Like a scientist, not like a religious zealot?

------
gavman
Vermont tried this a few years ago, they had to cancel it since in the end it
wasn't financially feasible [1]. CA is already dealing with severe budget
issues [2][3], so while it sounds nice in theory I'm hesitant to believe the
finances actually work out.

[1] [http://www.politico.com/story/2014/12/single-payer-
vermont-1...](http://www.politico.com/story/2014/12/single-payer-
vermont-113711)

[2] [http://www.latimes.com/projects/la-me-pension-crisis-
davis-d...](http://www.latimes.com/projects/la-me-pension-crisis-davis-deal/)

[3] [http://www.cnbc.com/2016/05/26/californias-revenue-
picture-d...](http://www.cnbc.com/2016/05/26/californias-revenue-picture-
dims.html)

~~~
mmanfrin
[2] is about CalPERS, which is separate from the budget of the State. There
may be a current budget shortfall, but CalPERS is fine (it is the largest non-
country pension fund in the world; and comes in the top 10 when listed among
countries).

[3] mentions that tax revenues will fall because of the end of temporary tax
increases; those increases are likely to be renewed.

Categorizing these as 'severe budget issues' is disingenuous and misleading.
California has had a _bumper crop_ in terms of tax revenue over the past
decade, and this stupid meme about California being out of money needs to be
corrected.

That being said, health care is not an inexpensive line-item, and will _have_
to be funded with taxes.

But as a Californian, I'm sure as shit happy to pay more in taxes for a
universal single single-payer. I have many friends who are either contractors
or who earn very little and find themselves in that uncomfortable valley of
having to pay for expensive insurance -- I'd rather that people (like me) who
are better off financially foot a bit more of a communal bill so that no one
would need to worry about it.

~~~
__realtime
> as a Californian...I'd rather that people like me...

There is crux of the issue: not everyone shares the same opinion and belief,
so should the government force those people to spend their earned income on
healthcare for others? Personally I think it won't end up how you anticipate
but that's just me. Right now the working people of America are already
subsidizing healthcare for the masses and all I ever hear is people
complaining about it.

~~~
hprotagonist
>not everyone shares the same opinion and belief, so should the government
force those people to spend their earned income on healthcare for others?

Yes. Ideally, that's what governments should do: require citizens to act in
our collective and long-term best interests, not only their own.

In the case of healthcare: a healthy population is a productive, happy, and
peaceful population. All of those things are good for the economy, not to
mention any one particular person's soul -- you can make a completely
utilitarian argument for it and largely sidestep thorny issues of morality.

~~~
mcbruiser
most likely what will happen is people will just leave CA, leaving a shortage
and it will fail

~~~
bsder
> most likely what will happen is people will just leave CA

Could you please inform our population here about that?

Republicans keep promising that people will flee the Blue states due to
various policies; somehow it never seems to happen.

Could you let us know what we're doing wrong? We'd really like to send some of
these folks to Red states to help balance out the voting.

Thanks bunches.

~~~
jeffbax
[http://www.sacbee.com/news/state/california/article136478098...](http://www.sacbee.com/news/state/california/article136478098.html)

"Every year from 2000 through 2015, more people left California than moved in
from other states. This migration was not spread evenly across all income
groups, a Sacramento Bee review of U.S. Census Bureau data found. The people
leaving tend to be relatively poor, and many lack college degrees. Move higher
up the income spectrum, and slightly more people are coming than going.

About 2.5 million people living close to the official poverty line left
California for other states from 2005 through 2015, while 1.7 million people
at that income level moved in from other states – for a net loss of 800,000.
During the same period, the state experienced a net gain of about 20,000
residents earning at least five times the poverty rate – or $100,000 for a
family of three."

Life in California is becoming a luxury good, largely due to its own policies,
and that is not a state in the right direction.

------
dragonwriter
Note that this bill, in its current form, has no substantive effect; it would
only "make findings and declarations with regard to the availability and
affordability of health care coverage and would state the intent of the
Legislature to enact legislation that would establish a comprehensive
universal single-payer health care coverage program and a health care cost
control system for the benefit of all residents of the state."

The actual legislation establishing single-payer health coverage and a cost
control system has not been proposed.

~~~
dang
Thanks, we added 'make findings' above. If someone suggests a better (more
accurate and neutral) title we can change it again.

------
wjossey
I'm excited to see this show up on hacker news.

As a Santa Monica resident, I'd gladly pay more in taxes for universal
coverage. The only way that we are going to achieve federal universal coverage
is via states paving the way. Just as "Romney care" was a predecessor to the
ACA, so can healthy California pave the way for the US to join the rest of the
modern world with guaranteed access.

~~~
darkstar999
Just curious why you would gladly pay more? Can you elaborate?

~~~
__jal
Can't speak for the poster, but I live in the Bay Area, and also would happily
pay more in taxes for this to happen.

That's because I think long-term, single-payer is the only sensible way to
handle health care. We have (the US has) a truly screwed up healthcare system
that (nearly) everyone acknowledges is inefficient, too expensive, wasteful
and less effective than it could be. Looking at other countries, this is
obvious.

Given the money involved, getting to single-payer will be a long-term project;
now even longer, to clean up the mess currently being made. It'll involve more
fighting, take longer, and be a more expensive transition than anyone likes.

Given all that, we have to start somewhere. I'm happy to start in my state,
even though I have great (employer-provided) healthcare, and could easily pay
for my own if I didn't.

There's also the aspect of doing the right thing, even at personal cost. I
think single-payer is the right thing to do.

So that's why.

~~~
dx034
It's certainly better than the current way, but single payer is not the only
way. Look at Germany for example, where the government sets minimum coverage
and the premium (in a band as a % of the salary which the state will pay if
you don't earn enough), but coverage is then provided by not-for-profit
entities. This allows some competition by eliminating inefficient providers
while making sure that everyone receives the same treatment.

I think such a system would work much better for the US as it's easier for the
state to build such a framework than to come up with health care for everyone.
The NHS (UKs single payer health provider) is the biggest employer in the
state, which gives you some indication on how complex it is to provide
universal healthcare for everyone.

------
rdmcfee
A single payer system is a step in the right direction, however, there are
deeper issues with the American healthcare system.

The unit cost of healthcare is so much higher than in other developed
countries.

In British Columbia, physicians bill at total of around $31 CAD ($23 USD) for
a standard office visit. They pay all their overhead out of this fee.
Typically doctors keep 65% of their billings and the offices take 35% for
overhead. From what I can tell, a similar visit in Washington State will run
between $60 and $200 USD when billed to insurance.

Why is this the case? What are the factors in the American system that prevent
reasonable pricing?

[http://www2.gov.bc.ca/assets/gov/health/practitioner-
pro/med...](http://www2.gov.bc.ca/assets/gov/health/practitioner-pro/medical-
services-plan/msc-payment-schedule-december-2016.pdf)

~~~
narrator
For one, doctors educational costs are astronomical in the U.S compared to
other countries. The amount of people able to become doctors is artificially
limited. Drug prices are unregulated. The cost of developing drugs is high and
has been getting higher.

Hospitals have little price transparency and the cost of same procedures at
different hospitals is wildly different. The same bag of saline can cost 10x
more at one hospital vs another. In markets where there is price transparency,
like Lasik surgery or other elective procedures, the prices are far more sane.

One thing that spending double as a percent of GDP on health care and getting
worse outcomes proves is that __THE SOLUTION TO THE PROBLEM IS NOT TO SPEND
MORE MONEY __. Unfortunately, this is the only thing American politics knows
how to do as more money means more money for every special interest with their
hand out.

~~~
chimeracoder
> The amount of people able to become doctors is artificially limited.

It is not artificially limited, and this is a common misconception that simply
won't go away.

The bottleneck is currently the number of people who can complete residency
training. Residency programs are not self-sufficient, so most of them are
funded by Medicare. That's not an artificial limit - that's a _natural_ one
(the sheer economics of the process).

~~~
SilasX
And (per previous discussion [1]) that doesn't explain it. If there is still
excess demand for MD degrees, then there is still room for potential MDs to
borrow any shortfall that residency subsidies won't cover.

The argument is like saying that Hamilton showings are limited by how much the
government will pay in subsidies for the tickets. No. The demand is enough to
cover expansion.

And even if it weren't there's still the issue of how much training is
_actually_ required to fill the functional role of a doctor. I'm pretty sure
that there's _some_ fat to cut out when you're making someone go all the way
through a bachelors before they can even start.

[1]
[https://news.ycombinator.com/item?id=13593944](https://news.ycombinator.com/item?id=13593944)

~~~
chimeracoder
> If there is still excess demand for MD degrees, then there is still room for
> potential MDs to borrow any shortfall that residency subsidies won't cover.

Because the amount of loan debt physicians have to take on is already massive,
and very few want to increase that by an _additional_ $112,000 (which is the
amount Medicare provides). There are some, but empirically, not many.

The term of that loan is comparable to many mortgages, and there's enough
uncertainty at this point in the expected payout that many qualified would-be
doctors are incentivized to choose other professions instead, where they can
make a pretty good living (and, possibly, a better one) _much_ sooner and
without the risk of taking out an _additional_ series of six-figure loans on
top of whatever may be outstanding from undergraduate education.

> The argument is like saying that Hamilton showings are limited by how much
> the government will subsidize ticket prices by.

Broadway ticket prices are a really bad analogy, because prices are
intentionally sold below market-clearing rate for a whole slew of reasons that
aren't directly comparable to the medical profession.

~~~
SilasX
>Because the amount of loan debt physicians have to take on is already
massive, and very few would want to increase that by an additional $112,000
(which is the amount Medicare provides).

Sure, _you_ think it's expensive, but the demand is still there, people are
willing to work for (net of costs) less than they currently are. That supports
the claim that the service is priced above the market clearing level. (Edit:
and they wouldn't be increasing debt by that full $112k; they could simply
provide 80% of the existing subsidy per slot instead of the current 100%.)

>Broadway ticket prices are a really bad analogy, because prices are
intentionally sold below market-clearing rate for a whole slew of reasons that
aren't directly comparable to the medical profession.

No, that makes it a better analogy, because it's a case of good sold below
it's market clearing price but which has excess demand capable of paying a
(much) _higher_ MCP, and where it's more obvious that the bottleneck isn't
(and can't be) insufficient subsidies.

~~~
chimeracoder
> Sure, you think it's expensive, but the demand is still there, people are
> willing to work for (net of costs) less than they currently are. That
> supports the claim that the service is priced above the market clearing
> level.

* There are more people who apply for publicly-funded GME every year than there are positions available, yes.

* However, almost nobody (roughly speaking) applies for self-funded residency positions (which do exist).

I don't know how those two facts combine to say that "the demand is there" \-
there is _not_ excess demand at market-clearing rates. There is only excess
demand at a subsidized rate. People are _not_ willing to work for less than
they currently are; the supply is highly substitutable, and we're already
seeing the effects of that.

~~~
SilasX
I added an edit that there is plenty of room between full current subsidy and
0% subsidy.

You're doubling down on the strawman of adding new slots at 0% subsidy, and
you're not considering the possibility that the requirements are too stringent
to begin with. (Full bachelor's plus MD plus full residency.)

Edit: Also, it wouldn't be "seeing the effects" of it until the number of med
school applications = number of med school slots.

~~~
chimeracoder
There is no "full current subsidy" \- the existing contributions from Medicare
are already a partial subsidy.

But this is kind of a meaningless debate after a point, because the number of
unmatched residents is already an upper bound on the number of additional
matches (you certainly wouldn't have more people interested when you increased
the price to them). And even then, we wouldn't see a huge difference - the
number of unmatched domestic applicants isn't enough to make a meaningful dent
in the labor supply of practicing physicians - and that's assuming all of the
unmatched doctors are as properly qualified as their matched counterparts.

In other words, no, we're not at the exact market-clearing rates for the
medical education market, and we consistently bias in one direction from that
equilibrium, but we're measurably not far off from it.

~~~
SilasX
>There is no "full current subsidy" \- the existing contributions from
Medicare are already a partial subsidy.

In the context, I meant "100% of current level"; I didn't mean to imply that
it was "full" in that sense (and my point didn't depend on such).

>t this is kind of a meaningless debate after a point, because the number of
unmatched residents is already an upper bound on the number of additional
matches (you certainly wouldn't have more people interested when you increased
the price to them)

You wouldn't have enough doctors if residents had to bear $1 extra in costs?
That is implausible.

With respect, this exchange does not feel productive.

------
marcell
I can't get over the cognitive dissonance of these two points:

> (2) Californians, as individuals, employers, and taxpayers have experienced
> a rise in the cost of health care and health care coverage in recent years

> (4) Individuals often find that they are deprived of affordable care and
> choice because of decisions by health benefit plans guided by the plan’s
> economic needs rather than consumers’ health care needs.

So (2) is saying health care costs are rising, which is bad. And (4) is saying
insurance companies are making decisions based on price, which is also bad.
You can't have it both ways. Either we should keep costs down, in which case
some procedures will be denied as they are too expensive, or we pay for every
procedure imaginable, causing prices to go up.

~~~
old-gregg
Yes you can. As a 6th largest economy in the world [1] California can
negotiate prices down by 50-60% to be comparable to Canada/UK. [2]

Besides, the existing state program (medi-cal) already covers over 1/3 of CA
residents [3]. So it looks like if we lower the cost by 60% we can get pretty
close to normal healthcare situation using the existing budget.

[1]
[https://en.wikipedia.org/wiki/Comparison_between_U.S._states...](https://en.wikipedia.org/wiki/Comparison_between_U.S._states_and_countries_by_GDP_\(nominal\))

[2]
[https://www.washingtonpost.com/news/wonk/wp/2013/03/26/21-gr...](https://www.washingtonpost.com/news/wonk/wp/2013/03/26/21-graphs-
that-show-americas-health-care-prices-are-ludicrous/?utm_term=.09e01c5211e5)

[3] [https://en.wikipedia.org/wiki/Medi-
Cal](https://en.wikipedia.org/wiki/Medi-Cal)

~~~
marcell
Some of the numbers for [2] confuse me. How can an office visit cost $30 in
Canada? When I go in for an office visit, it typically takes about 30 minutes
of staff time, around 15 minutes with a medical assistant and 15 minutes with
a doctor. If that's $30, the implied wage is $60/hr for the medical staff,
_if_ you assume that all the money goes to staff. That just doesn't seem
feasible.

Some of the other numbers seem more reasonable, though I should point out the
charts are a bit misleading as they list the US 95th percentile in addition to
the averages, which makes the difference appear larger than it really is.

~~~
seanieb
A doctors visit isn't a good example. Folks don't go bankrupt from doctors
visits. The important stuff is drugs and hospitals.

For example an asthmatic in any other country in the world pays ~$10 for a
Ventolin inhaler (including tax and a % of profit), Americans pay $55-$65 and
that price is increasing.

------
Keverw
Seems like an interesting idea. With California being the only state in the
country doing this, I wonder what is there to stop people from other states
using it. Someone from Washington or Texas driving up and getting a short term
apartment/changing their ID just so they are covered for a really expensive
surgery.

It seems like if they're the only state doing it, it'd be a target for the
entire nation to go to when they really need care they cannot afford where
they are currently.

~~~
birken
You could say the same thing for people qualifying for in-state tuition to
University of California colleges (which is significantly cheaper than out-of-
state tuition). Just moving to CA and making yourself a CA resident isn't
enough, I think the rule there is you need have physically lived in a
residence in CA for 1 year and intend to stay living in CA.

No reason why they couldn't make a similar restriction for health care.

------
11thEarlOfMar
If this would replace my private health insurance premiums with State taxes,
I'd have about $21,600 to contribute for a family of 4, generally healthy
humans.

\- Does it mean no such thing as 'in or out of network'? That alone cost me
$10,000 in 2015, over an above the $21,600 premiums.

\- Will it be PPO or HMO-style? Some of us like Kaiser, some don't.

\- Will I be forced to change providers? A real sore spot from the ACA for me.

I guess I'm saying, do it, but for God's sake, get it right the first time.

~~~
tarr11
As a CA small business owner, I'd be much happier to just pay a simple payroll
tax per employee than have this multi-step octopus process around open
enrollment periods, health insurance brokers, differing city regulations (like
SF), multiple vendors, audits, etc.

Single payer would also make hiring and HR a lot simpler.

------
cdransf
Anything that moves us beyond the gross waste and incompetence of insurance
and medical billing is a good thing.

My wife and I had a few recent medical issues crop up and, despite having
decent coverage, have had to deal with chasing down providers and third
parties who consistently fail to bill even the most basic procedures properly.

I'd much rather pay more in taxes to have the knowledge we'd be safely covered
without dealing with the headache of endless middlemen who add no value to the
system.

------
consultutah
I think this is great. California gets to experiment with a single payer
system and I, as a Utahan, get to watch and see whether it works or not.
Unless it completely fails, then we'll all need to bail Cali out. Can we try
this in North Dakota first? ;)

~~~
Joof
Worked for many other countries. Seems to be quite a bit cheaper for
individuals and nations as well. Not sure if it will work on a state level
though.

~~~
darkstar999
Only if CA can negotiate lower costs, especially pharmaceuticals.

~~~
086421357909764
and establish uniform pricing for services across the board

~~~
darkstar999
Not sure if that's totally fair, Califoria is very diverse. Rates that work in
SF might not work in rural CA.

~~~
fsargent
It's reasonably easy to establish pricing differences relative to land value
costs to account for increased rent in the area. It's almost the same way the
GSA determines Per Diem rates.
[https://www.gsa.gov/portal/category/100120](https://www.gsa.gov/portal/category/100120)

------
knodi
I will 100% be moving to Cali if this passes. I won't mind paying higher taxes
for this as well. Right now my shit health care plan costs me $260/month in
MI. If the taxes increase by 300-400/month I'm all for it and will gladly pay
it.

------
luckydata
California is roughly the size of Italy, its economy slightly larger but
essentially comparable. Italy has single payer and one of the best healthcare
outcomes in the world with one of the lowest expenditure per patient in
developed countries. Quality of service is uneven geographically (but it's no
different anywhere else) and in generally getting care in Italy is a no hassle
experience.

California, learn from Italy.

------
unethical_ban
I congratulate the senators on proposing universal health-care in a way that
in federally Constitutional: that is, through the states!

Though I'm usually skeptical of government overreach and innefficiency, I do
believe a minimum of preventative care would save people and the system a lot
in terms of money, time, and life. So go for it, and let the rest of the
country see how it goes.

------
dpc_pw
Coming from a country with single-payer healthcare:

If you have have 5 beds, and 10 people that need to use a bed every day, there
is no pure finance management solution to solve it.

If you have insurance-based system like in US, only people who can afford
insurance will be able to use the beds. Rest will be priced-out.

If you have single-payer system like in my country of origin (and what a lot
of people in America would want), people will be queued and/or to some extent
squeezed to fit on what's available. It often leads to corruption, when people
pay extra to cut the line. Or there are some officially approved way to pay
your way to get your bed fast and without overcrowding.

The reality is of course a bit more complicated, but the point is: the real
solution is to either have more beds, or to have less people who need to use
them. Why can't more beds be built and operated cheaply? Why there is so many
people needing them?

~~~
joshpadnick
_> The real solution is to either have more beds, or to have less people who
need to use them._

This is exactly the incentives we've wanted all along. Is healthcare too
expensive to cover everyone's current level of need? Now it finally makes
sense for government to get serious about investing in prevention.

Our current incentives of "the more sick-care you provide, the more you get
paid" has exactly the opposite incentive. No solution is perfect, but this
feels like a significant step in the right direction.

------
ThomPete
Here is the problem. How do you deal with illegal immigrants? At least in the
current system there are ways for them to get treated, but in a single payer
system?

Single-payer works great in countries were everyone have a ssn. Not sure its
feasible in the US as much as i think it would be great.

~~~
amluto
By giving them healthcare? There aren't actually a large number of illegal
immigrants sitting around contributing nothing to the CA economy.

~~~
FT_intern
I did a quick search and an estimated 11 million illegal immigrants pay an
estimated $11.6 billion in taxes, so $1,000 per person.

It's a huge net loss. Not to mention the fallout from stolen SSNs and creating
demand for stolen SSNs

~~~
some-guy
When I worked a minimum wage job after high school full time I paid zero in
taxes, and I'm a citizen.

~~~
DrScump
We're not counting working illegally, "under the table".

Even (legal) minimum wage workers pay full FICA and Medicare tax.

------
cmdrfred
I don't think single payer is viable in the US, yet I am happy that it is
being attempted here. America was originally designed to be a marketplace of
ideas. With a limited federal government each state can enact laws that it
sees fit. If the law works well, more states will adopt it.

This is a perfect example of "states rights" at work. I hope it gets
implemented (if the people of California wish it so) and that comprehensive
data is provided so I and others can make a truly informed decision on the
matter.

------
darkstar999
I don't understand this. Maybe I'm uneducated on "acts"?

> It is the intent of the Legislature to enact legislation that would
> establish a comprehensive universal single-payer health care coverage
> program and a health care cost control system for the benefit of all
> residents of the state.

This is literally the meat of the bill. The actual changes would still have to
be voted on in separate bills, right? What is the point of this?

~~~
jkimmel
The CA legislature uses a good deal of intent legislation. I assume the
purpose is to formally announce the beginning of legislative development
process, allowing stakeholders to become involved.

------
AdeptusAquinas
Welcome to the rest of the civilised world.

------
bawana
if health care prices were mandated to be public (like calorie counts on food)
then we would all be better off

~~~
cortesoft
Knowing health care prices doesn't help much, though. If you break your leg,
you aren't going to go to a bunch of different hospitals, compare prices, and
choose the best value option. If you are in a car accident and unconscious,
the paramedic isn't going to figure out where you can get the best deal.

Medical decisions are a TERRIBLE candidate for a free market. You are never in
a position to be a rational actor in them.

------
michaelchisari
Healthcare is such a massive hurdle to entrepreneurship, this would be huge!

~~~
ThomPete
It has very little effect if any. denmark have a true single payer system and
social wellfare program you can only dream of in the us. Yet the number of
startups created are declining just like ine the us. It creates a very
different mindset.

~~~
nikdaheratik
We don't know what the effect would be since we've never had a single payer
system. In addition, Europe has a number of other labor laws that do not exist
in the U.S. as well as other corporate regulations so there is no apples-to-
apples comparison.

So I agree that adding single payer or changing the healthcare system to have
more government involvement probably won't have much effect, but I don't agree
that the single-payer + welfare system is the reason why they have different
levels of startups in Denmark.

~~~
ThomPete
Not what i said. Look at parent to what i am answering. Current system was
positioned as a burden for startups, my point is simply that healthcare is a
burden no matter whst and that changing the system wont make it less a burden,
it will just have consequences other places.

------
ghufran_syed
Given how much this country honours its armed forces, I guess we can
reasonably expect the standard of care and efficiency to be, at most, equal to
that of the Veterans Administration (VA)

------
cft
Will there be a private insurance alternative? Many of my parents' Canadian
friends visit the US for complex procedures and surgeries (because of both
quality and wait times).

------
fishywang
Assuming this is implemented, how does it work in case of Californians
traveling in other states/countries? Will it work like the current out-of-
network case, that the government reimburse you some percentage, with some
restrictions (ER only, for example)? Or will the Californians need to buy a
separated insurance before they travel?

How does this work for single-payer countries, like Canada?

------
exabrial
Who will pay for it?

~~~
mmoche
All of its residents.

~~~
DennisP
In theory they could have a problem with really sick people moving to
California for the healthcare, raising their costs. But that takes time, so
maybe before it becomes a big problem, other states will do similar things.

~~~
kcorbitt
This isn't really an "in theory." Welfare states are fundamentally
incompatible with open borders until we live in a world where equivalent
levels of welfare are available everywhere. The incentives just don't add up.

On the other hand it could still work if the benefit is only available to
Californians who have lived there for X years. Not sure about the legality of
this though -- states can discriminate this way for in-state University
tuition, but in Zobel v. Williams the Supreme Court ruled that Alaska couldn't
pay out Permanent Fund dividends based on how long you had lived in Alaska
([https://en.wikipedia.org/wiki/Alaska_Permanent_Fund](https://en.wikipedia.org/wiki/Alaska_Permanent_Fund)).

------
deepnotderp
This is gonna be great for a startup in California!

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tlrobinson
Seems like a bit of a work in progress...?

------
jljljl
I wonder what the impact would be on the US insurance market if the state with
the largest GDP dropped out?

------
home_boi
What effects would this have on the currently generous insurance plans of
$huge_tech_company_based_in_CA?

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gator-io
I simultaneously believe in universal coverage as a moral imperative, but also
the efficiency of markets over government AND basic income as a necessity as
automation displaces millions of workers.

So, why not combine concepts - start off with basic income that has to be
spent on health care insurance. Start with enough for coverage against major
issues, but people can spend more for more coverage.

Universal coverage is attained immediately without any individual mandates.
Giant, wasteful bureaucracies go away. Prices are controlled via market
forces.

And it paves the way for a system of basic income...

~~~
neltnerb
I'm pretty confident that if you get rid of individual mandates while not
disqualifying sick people or enforcing benefit caps, premiums will skyrocket.
I'm not sure there's really a middle ground here, it's just unavoidable
actuary math.

So if it is, as you say, a moral imperative, what are your choices?

Maybe the EBI will need to be ridiculously high to actually provide the
coverage you agree is a moral imperative to provide. But that doesn't really
solve the problem, it just ends up meaning that sick people don't have that
EBI to cover stuff everyone else can pay for with it. Like food and housing.

I'm open to hearing other ideas on how to do it, but I think that you'd have
to vary the EBI based on how expensive health care is for the individual
getting it, if your goal is to meet the universal coverage moral imperative.
And that's very different from what EBI is supposed to be. I don't think it
will solve the problem that you're describing.

~~~
gator-io
The individual mandate is moot in this system, as everyone will have money
they can only spend on insurance.

Benefit caps are a really tricky issue. As a society, are we willing to spend
a million dollars to extend life for a week? Probably not. On the other hand,
do you cut off a cancer patient after a million? Probably not. But there has
to be a rational way to balance this without people freaking out over 'death-
panels'.

I agree, universal coverage means vastly more money spent. Therefore, coverage
for major issues is the baseline amount, not the Obamacare standards where
people generally have way more insurance than they would choose.

The closest proposal I've seen is tax credits for this.

~~~
neltnerb
If they can only spend the EBI on insurance, it's a fixed health care subsidy
or tax credit depending on how you frame it. I may simply be confused though,
because every example I know of for EBI means "unrestricted base income".

Can we just call it something other than EBI if you're talking about
restricting how it is spent?

In any event, if I understand you, it's a fixed amount per person.

That doesn't seem like it does much to address the moral imperative of
guaranteeing affordable health care if sick people are on much more expensive
health care plans or if the available affordable plans don't cover what they
need. So you'd have to offer varying amounts depending on need, in order to
meet that moral imperative.

And once you're talking about varying the amount, it is not very close to what
I think you're describing.

Is there some way to reconcile these ideas and constraints that I'm missing?
Because I suspect Congress would love to hear it...

------
nickff
The problems with your last argument are that almost nobody is actually a
utilitarian, and utilitarianism is wrong.[1][2][3]

edit: full disclosure; I am an ethical intuitionist.[4]

[1]
[http://degreesofclarity.com/writing/utilitarianism/](http://degreesofclarity.com/writing/utilitarianism/)

[2]
[https://en.wikipedia.org/wiki/Trolley_problem](https://en.wikipedia.org/wiki/Trolley_problem)

[3]
[https://en.wikipedia.org/wiki/Utilitarianism#Criticisms](https://en.wikipedia.org/wiki/Utilitarianism#Criticisms)

[4]
[https://en.wikipedia.org/wiki/Ethical_intuitionism](https://en.wikipedia.org/wiki/Ethical_intuitionism)

~~~
stale2002
The Trolley problem isn't really an example of utilitarianism being wrong.
Quite the opposite, I use that example to convince people of how awesome
Utilitarianism is, not as a contradiction.

What, would you chose to kill 5 people, instead of one?

~~~
nickff
I gave that as an example of a controversial subject; many people prefer to
let things be rather than interfere and kill one or more people. The organ
donor example is much tougher.

------
mindcrime
_so should the government force those people to spend their earned income on
healthcare for others?_

Absolutely not. Pretty much any question that starts with "should the
government force ..." can be answered "no". You earned your income, it's yours
and it should be up to you how to spend it.

Using force / aggression (aka the government forcing you to do something) is a
violation of your most fundamental rights, and strips you of your agency and
dignity as a human being. And while the end may sound noble ("everybody should
have free health care") the truth is that nobody is in a better position to
determine how your income should be spent than you, and nobody other than you
has any standing to decide what kind of charity (if any) you should engage in.

Rather than stealing from Bobby to pay for Suzy's health-care, it would be
better to enact policies that A. reduce the cost of health-care, and B.
encourage general economic welfare, job creation, etc., such that both Bobby
and Suzy can pay for their own health-care from the get-go.

~~~
hackuser
Government is "forcing" very few people. Most people participate in society
voluntarily.

For example, government doesn't force me to obey the law; I do it voluntarily.
They don't force me to pay my bills, not shoot my neighbor, and pay my taxes.
I do all that voluntarily.

EDIT: I don't follow Hacker News' rules and norms because I'm afraid of being
banned, but because I respect the other people here, respect that there need
to be rules, and respect our hosts' authority and need to make them. It's
something (almost) all learn as children; it's healthy social interaction.

Most people are responsible members of their communities. The concept of force
applies only to a very few.

~~~
white-flame
> For example, government doesn't force me to obey the law; I do it
> voluntarily. They don't force me to pay my bills, not shoot my neighbor, and
> pay my taxes. I do all that voluntarily.

That sounds like the IRS's shtick about income taxes being "voluntary". From a
technical perspective, these decisions are under duress, under threat of legal
repercussion, even if you find that choice agreeable and would act in the same
way without the law involved.

~~~
hackuser
> From a technical perspective

I'm not sure what this means. I'm aware of the theoretical argument.

The great majority obey the law because they want to. The threat of jail is
actually minor; you can get away with quite a bit.

------
masterleep
We are doomed.

~~~
darkstar999
How so?

~~~
brutus1213
This will likely be funded from income tax. As a mid-30s person who earns a
decent tech salary and has zero hope of buying a house in the decent parts of
the SF Bay area, I think this is another case of taking from the young to feed
the old. We should totally do this single-payer thing and pay for it via a
wealth tax (that takes the current price of your home into account). Lets make
it tiny .. say 0.5% a year.

~~~
darkstar999
> As a mid-30s person who earns a decent tech salary

... you can afford it. Moreso that others. You _are_ the wealth.

~~~
tylersmith
He can afford it. Others can't. Why should he pay for them just because they
have a lower value?

~~~
cortesoft
So these 'lower value' people should just die when they get cancer?

I find the idea that not being able to earn a high enough salary means you are
unworthy of basic medical care repugnant.

~~~
brutus1213
If you read my post, I said I was in favor of this as long as it doesn't
burden income earners. Some degree of health care and education are basic
human rights in my opinion.

If you want everyone to have the "Cadillac" health plan and education plan,
you need to tell me how society will pay for it? And lets talk sustainable
plans .. no more kicking down the can to our kids and grand kids.

Finally, to all the negative commentators on my post, please read up on the
difference between wealth and income. At current rents, factoring current
child care costs, lack of pensions and existing tax rates, someone who makes
200K in California is worse off than someone who owns a detached house in
Mountain View and a few other properties (by virtue of being here from the
Orchard days), and then hides his/her income. I've seen too many people like
that at this point in my life. Enough is enough.

