
What Killed Single-Payer in California? - rbanffy
https://newrepublic.com/article/143650/killed-single-payer-california
======
JonFish85
In a word, the answer is still "cost". You can try to dance around it and talk
about how " A single-payer program would inevitably incur additional taxes,
but the overall health care costs would be lower for most people and
businesses", but at the end of the day, it's going to cost a lot of money.
This article claims it'd "only" cost about an additional $100b or so in CA; I
think critics would be very skeptical of that, especially since costs are
claimed to come from "reduced overhead" areas. I'm not sure that governments
have a history of keeping costs low, so voters would likely be skeptical of
that.

Ultimately I imagine it boils down to voters in a state with already very high
taxes (by American standards) being very wary of voting to significantly
increasing their taxes again.

~~~
twoodfin
Agree cost is a huge factor, but another key issues is the inconvenient fact
that most Americans with employer-provided coverage are satisfied with it.
Convincing them to take a leap into the dark with no credible promises that
they could still see the same PCPs and specialists they can see today and with
similar wait time/referral requirements would be politically Herculean.

~~~
jellicle
> they could still see the same PCPs and specialists they can see today

What do you think single-payer is? There's no such thing as "out of network".

~~~
twoodfin
I don't think single-payer works the way you seem to think it does in nations
where it's been implemented.

I have an expensive employer-provided plan. I can, without any referral, make
an appointment with a specialist (surely making $300K+) at a top teaching
hospital and expect to wait weeks at the most.

There is no way to offer that level of service to anyone and not explode
costs, let alone contain them.

~~~
pg314
> I don't think single-payer works the way you seem to think it does in
> nations where it's been implemented.

I don't think single-payer works the way _you_ seem to think it does.

> I have an expensive employer-provided plan.

I'm happy for you. What happens when you lose your job?

I live in Belgium. I'm covered by the basic social security health insurance,
just like any other Belgian.

> I can, without any referral, make an appointment with a specialist (surely
> making $300K+) at a top teaching hospital and expect to wait weeks at the
> most.

So can I. I've never had to wait more than a couple of weeks at most. If it's
urgent, they fit you in on the same day or a couple of days later at the
latest. That seems to be corroborated by [1]. One exception is mental health
care, where the waiting lists are long.

> There is no way to offer that level of service to anyone and not explode
> costs, let alone contain them.

That is wrong. According to [2], health spending accounted for 10.9% of GDP in
Belgium in 2012, which is much lower than the 16.9% the US spends.

[1] [http://focusonbelgium.be/en/international/belgium-has-
shorte...](http://focusonbelgium.be/en/international/belgium-has-shortest-
waiting-time-healthcare-europe)

[2]
[http://webcache.googleusercontent.com/search?q=cache:2VeNWmB...](http://webcache.googleusercontent.com/search?q=cache:2VeNWmBzMy0J:www.oecd.org/belgium/Briefing-
Note-BELGIUM-2014.pdf+&cd=1&hl=en&ct=clnk&gl=be)

~~~
twoodfin
The Belgian system contains costs in other ways. For example, doctors
(especially GP's) are paid significantly less. Belgium is also over 10x as
population dense as the U.S., which offers significant opportunities for more
efficient care delivery.

Anyway, it's not clear to me that Belgium has anything like a single-payer
system[1]:

 _The Belgian population enjoys good health and increasing life expectancy of
79.5 years (2004). Most Belgians have access to health care of high quality,
financed mainly through social security contributions and taxation. Compulsory
health insurance is combined with a mostly private system of health care
delivery, based on independent medical practice, free choice of physician and
predominantly fee-for-service payment._

That doesn't sound at all like single-payer.

[1]
[http://www.euro.who.int/__data/assets/pdf_file/0007/96442/E9...](http://www.euro.who.int/__data/assets/pdf_file/0007/96442/E90059.pdf)

~~~
pg314
> The Belgian system contains costs in other ways. For example, doctors
> (especially GP's) are paid significantly less.

That's exactly the point! Single-payer is much better at containing the costs.
The cost of a GP's visit is fixed centrally. And somehow we still end up with
more doctors per 1000 inhabitants than the US.

> Belgium is also over 10x as population dense as the U.S., which offers
> significant opportunities for more efficient care delivery.

States like New Jersey and Rhode Island have higher population densities than
Belgium. Is health care significantly cheaper there? A cursory glance at [3]
suggests otherwise.

One big difference between Belgium and the US is that damages in malpractice
suits are not determined by jury, and hence much lower.

> Anyway, it's not clear to me that Belgium has anything like a single-payer
> system[1]:

What is your definition of single-payer healthcare? If I look at wikipedia
[1]: _Single-payer healthcare is a healthcare system in which the state,
financed by taxes, covers basic healthcare costs for all residents regardless
of income, occupation, or health status_.

The Belgian health-care system covers everybody, financed by social security
contributions and taxation. The compulsory health insurance is about 75 EUR
per year, and amounts to simply another disguised tax. What is not single-
payer about that?

There are deductibles for doctor's visits (e.g. 6 EUR for a GP visit), but
your total healthcare costs are capped at 459 EUR per year (even lower for
low-income families). Anything over that is covered by social security.

You can get optional, extra health-insurance which can cover additional
services. E.g. if you prefer a single room when you are hospitalised, that
costs extra. Some extra health-insurance covers nonsense like homeopathy,
which is otherwise not covered.

Btw, dental care is included in basic coverage. No third-world country
situations like [2].

[1] [https://en.wikipedia.org/wiki/Single-
payer_healthcare](https://en.wikipedia.org/wiki/Single-payer_healthcare)

[2] [http://www.washingtonpost.com/sf/national/2017/05/13/the-
pai...](http://www.washingtonpost.com/sf/national/2017/05/13/the-painful-
truth-about-teeth/?utm_term=.e6e240695895)

[3] [http://www.kff.org/other/state-indicator/health-spending-
per...](http://www.kff.org/other/state-indicator/health-spending-per-
capita/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D)

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emilecantin
Yeah, "free" healthcare is expensive for sure. Here in Quebec, I'd guess that
it's around 40%-60% of the overall province's budget. Sure, it means higher
taxes, but we don't have to deal with health insurance. How much do people (or
their employer) pay for that in California? 300$ / month? I'm pretty sure my
(provincial) taxes are not 3.6K higher than someone in California.

People mention better access to specialists in a privatized system... I'd
argue the peace of mind of not having to worry about healthcare costs far
outweigh whatever advantages a privatized system may have.

~~~
snomad
10 years ago I paid $140 per month ($1,500 per year) for a great healthcare
plan. Last year, my employer (w/over 5k employees, so I am hoping some
discount) paid 10k for a great health plan. Both are California numbers.

~~~
emilecantin
That 10k, is it per person, or total? I find it hard to believe you can get
health insurance for 2$ / person!

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ChrisBland
As bad as some private insurance is; having friends and family who must seek
care at the VA makes me want to run far far away from single payer. We have
failed our members of the armed services, what makes you think we would do
better for Joe & Jane Schmoe than we do for them? Larger organizations fester
with waste and mismanagement the bigger they get, its simply a law of nature.

~~~
jernfrost
That is not single payer though. They run the hospitals as far as I know, so
it is more like socialized health care. I actually thought VA was good from
what I've read/heard.

Anyway a problem with a public option for the few is that there will be no
political pressure to make it good. You see this in every country which offer
public and private options, where the rich primarily chose private. The public
option turns into crap because the very people who could have put heavy
political pressure on the public option don't care.

This is the experience we've had in Norway at least through history. If you
want good public services, they need to be universal and apply to both rich
and poor people. Means tested solutions only for the poor or disadvantaged
always end up crappy. When somebody is universal, everybody gets a stake in it
and a desire for it to be good, including the politicians who get elected.

If all the politicians and the bankers on wall street had to use VA, you can
bet it would have offered great service.

Once great example of this dynamic is from the 60s when they forced mixed
schools in the US. "black schools" which suddenly got white students, suddenly
got all sorts of maintenance work taken care of. Those schools got big
upgrades due to that. In short if people with power and influence has to use a
system, it will get a lot better.

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dmh2000
it would be nice for those supporting single payer to first describe exactly
how the funding would work. Instead of trying to hide it under a mismash of
taxes, like Obamacare, just come out and say (for example), there will be a X%
tax added to FICA, where the employee will pay 1/2 and employer pay 1/2\. Or a
VAT tax. Or whatever. Just come out and say what it will cost instead and how
it will be funded. Instead its always about the benefits while avoiding any
mention of new tax.

just be honest about it.

~~~
jernfrost
That seems to be a problem in the US, that people are so afraid of talking
about taxes. It should be hard to be honest about it though, as one can make a
calculation about how much people pay out of pocket and through company
provided health care today, and compare this to how much it would cost in
taxes instead.

I would probably have used VAT for this.

~~~
WalterSear
The word's been weaponized by the right.

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carsongross
NB: the US _already_ spends more on socialized medicine than any other country
except Norway:

[https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...](https://en.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_per_capita#/media/File:OECD_health_expenditure_per_capita_by_country.svg)

The US spends more on _socialized_ medicine than countries like Japan and
Great Britain spend in total.

It is a very bad situation here in the US.

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jernfrost
I don't get why they make this so complicated. It is not like this costs any
more than the existing system. You are just paying for it in a different way.
Rather than paying the insurance system directly you are paying the tax man.
Whether you pay the insurance company 100 bucks or the tax man, shouldn't make
a difference.

~~~
chimeracoder
> It is not like this costs any more than the existing system

The budget estimates indicate that it would be about 50% more expensive than
the status quo, after accounting for private expenditures.

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golemotron
> A legislative analysis found that California’s single-payer plan would cost
> $400 billion to implement, $200 billion of which would be new spending.
> Critics were quick to point out that this “hefty” price tag is twice the
> state budget. Furthermore, the bill did not include a funding plan.

Amazing they needed a whole article to say this. How disjointed from reality
do people have to be to go through the legislative process with something that
fiscally infeasible?

~~~
bpodgursky
California legislators have learned that they can appeal to their rabid left
wing by passing unrealistic bills, and Jerry Brown will play the adult in the
room and veto them. So there's not really any danger to the legislators. It's
a game they all understand.

