Should California Pass Single Payer?

[Northern Light]

California's economy is larger than that of nation-states which support Single Payer. This claim is incorrect.

California isn't a nation state, so the comparison is flawed. It has porous borders with other states and as soon as it passes a single-payer system people from all over the country will flock there for health care, rendering it another bloated, expensive system.

 

[Cephus]

California should start small...probably pass "Calicaid", a state funded public option that those who make too much to qualify for Medicaid could buy into and which would compete against the private plans. I bet once a public option for insurance is available you will see a massive drop in premiums.

Not unless you saw a massive drop in costs, which nobody is even trying to address. Premiums are high because it simply costs a ton of money to do business in the medical field. That has to change before we'll see premiums go down.

 

[Surrealistik]

California isn't a nation state, so the comparison is flawed. It has porous borders with other states and as soon as it passes a single-payer system people from all over the country will flock there for health care, rendering it another bloated, expensive system.

I think that with photo IDs and a lengthy residence requirement, this sort of migration will prove much less problematic in practice.

 

[colorado cowboy]

No ---- if they pass it, all the Californians will try to move to Nevada or Colorado .... and we damn sure don't want them.

 

[RabidAlpaca]

Who says California have to provide this for non-Californians?
Although it's good to see lefty's admit that an overly-generous welfare state, combined with lack of border control, is unsustainable....

Because in the US you can change your state residency at will. I'm not sure how you don't understand that insurance requires the healthy populace to pay into it over time, not just jump in and out based on urgent medical care you need.

Also, single payer isn't welfare, the population pays into it and they get a return, like any insurance, but it costs a fraction of our current system.

Why not? If the federal barriers to implementing a state-based single-payer plan could be cleared, why not let them experiment with it?

Single payer can't function if people can jump in and out of the insurance pool simply by moving in and out of state.

A citizen of Louisiana getting a $500k medical bill from our current ****ed up system simply moves to California for treatment, and when the system implodes it'll be seen as a failure of single payer and not the ridiculous system that served up a $500k medical bill over simple **** in the first place.

 

[cpwill]

Because in the US you can change your state residency at will. I'm not sure how you don't understand that insurance requires the healthy populace to pay into it over time, not just jump in and out based on urgent medical care you need.

Also, single payer isn't welfare, the population pays into it and they get a return, like any insurance, but it costs a fraction of our current system.



Single payer can't function if people can jump in and out of the insurance pool simply by moving in and out of state.

A citizen of Louisiana getting a $500k medical bill from our current ****ed up system simply moves to California for treatment, and when the system implodes it'll be seen as a failure of single payer and not the ridiculous system that served up a $500k medical bill over simple **** in the first place.

No, a citizen of LA thing a $500k bill owes $500k. They would have to have moved to CA and established residency for however long to avoid that bill by falling under SP, but they could have done that much more cheaply simply by purchasing insurance.

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[holbritter]

The difference is that almost all of Europe has some form of single payer healthcare with near 100% of their citizens insured. If one state in the US did it, when people get sick and their own state's healthcare system would massively **** them over and send them into astronomical debt, they would temporarily move to California as a medical tourist to get treatment.

Americans already do this with other nations and instead of blaming the ****ty healthcare system that created the situation in the first place we'd blame California's for not having a sustainable system because they're being flooded with people from out of state who won't spend years before and after their issue paying into the system. A single payer system can't work if people just pop in for treatment then leave.

What if they made it so you have to be a legal resident for some period of time before you could be insured?

 

[molten_dragon]

Yeah, let's try it out and see how it works.

 

[RabidAlpaca]

No, a citizen of LA thing a $500k bill owes $500k. They would have to have moved to CA and established residency for however long to avoid that bill by falling under SP, but they could have done that much more cheaply simply by purchasing insurance.

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Not really, if we go back to pre-Obamacare like the GOP wants insurance companies can just flat out deny a payout to even a long time insurance holder because it's more money than they want to pay. You can pretty quickly hit your lifetime limit then you're just straight up ****ed, no matter how insured you think you are.

What if they made it so you have to be a legal resident for some period of time before you could be insured?

That might prevent some people from moving shortly after becoming sick but it doesn't stop all medical tourists and it doesn't keep them there and paying insurance after they get their treatment.

 

[Surrealistik]

That might prevent some people from moving shortly after becoming sick but it doesn't stop all medical tourists and it doesn't keep them there and paying insurance after they get their treatment.

Let's keep it real; most people, probably even a vast majority, aren't going to move to Cali for a year or more (or however long it is) to fulfill the residence requirement, get treatment, then immediately **** off (especially since it would take them yet another year+ of residence to get SP coverage again).

 

[Cephus]

No, a citizen of LA thing a $500k bill owes $500k. They would have to have moved to CA and established residency for however long to avoid that bill by falling under SP, but they could have done that much more cheaply simply by purchasing insurance.

I might not say if there was a residency requirement of, maybe 2 years, before you could get any benefits at all. At least 2 years of being a LEGAL, demonstrable, tax-paying citizen of the state before you qualify for single payer health care. But we all know that the liberal assholes in Sacramento want to cover all of the illegal aliens, which means there will be no requirement at all. They'll just take all comers. It will be absurd and drive a lot of people out of the state.

 

[Northern Light]

I think that with photo IDs and a lengthy residence requirement, this sort of migration will prove much less problematic in practice.

Then it's not truly single payer.

People are comparing CA to a nation state, but in Canada if you end up in the ER, even as a foreigner, you get full treatment. And every health condition if allowed to get serious enough ends up in the ER. You may get billed for some services but you get billed after you are treated -- your treatment it not decided based on whether or not you can pay. There is no two-tier system. Everyone gets the same treatment they need regardless if the government ever gets paid for it.

If CA wants to be single-payer then that's what would happen. I see many people out of state making trips to CA and conveniently ending up in the ER.

 

[Slingshot Bob]

I say sure, let them be the experiment, sink or swim.

 

[Surrealistik]

Then it's not truly single payer.

People are comparing CA to a nation state, but in Canada if you end up in the ER, even as a foreigner, you get full treatment. And every health condition if allowed to get serious enough ends up in the ER. You may get billed for some services but you get billed after you are treated -- your treatment it not decided based on whether or not you can pay. There is no two-tier system. Everyone gets the same treatment they need regardless if the government ever gets paid for it.

If CA wants to be single-payer then that's what would happen. I see many people out of state making trips to CA and conveniently ending up in the ER.

In Canada, if you're a foreigner, though you will certainly get treatment, you will pay for everything. In fact, treating foreigners is big business in Ontario to the point it's potentially problematic: Public hospitals profiting from foreign patients - Toronto | Globalnews.ca

Provinces also have a residency requirement.

 

[Greenbeard]

Not at all an article of faith; it is a statement based on consistently demonstrated outcomes. SP indeed works largely by setting prices through negotiation, economy of scale and clout. When you have monopoly or near monopoly power on payouts in a state like California, you obviously have immense bargaining power. As stated several times previously prices are inflated precisely because there are no controls, and because insurer middlemen vampirize value and create considerable administrative expenses. SP does away with both of these things in a very big, very real way. The is an obvious and considerable difference between trying to bend the cost curve and expenses in this tried and true way, and through absurd, needlessly roundabout solutions that have largely been ineffective.

This is exactly what I said. You're leaning entirely on the notion that we can always rely on price controls to tamp down rising costs if necessary.

In large part, the objective here is to have a weapon to wield against labor--one in eight jobs private sector are in the health sector, so there's plenty of money to be squeezed out of the system by cracking down on them. I'm not convinced forming a government monopsony with that intent is the best way to proceed.

You're omitting the sprawling administrative costs these insurers impose on the system directly and indirectly:

I was specifically talking about the amount private payers currently directly spend on drugs and devices.

Why wouldn't it work to tackle those inputs and the pass through of those expenses? That's a core point, alongside eliminating administrative and billing bloat.

It doesn't need to buy the inputs, so much as set and negotiate prices within the state, though I certainly wouldn't be opposed to SP initiatives to work with providers to minimize costs on a more direct basis.

Your single-payer entity is also going to set the prices of the inputs bought by providers? Will it directly set the wages they can pay employees, as well?

Insurers have no role in SP nations save for, at most, travel health insurance and non-essential/supplemental care/therapeutics/cosmetics and peripherals.

I'm talking about the United States. What functions are and need to be served? That's a question worth thinking about before tearing up the current system and attempting to plop down a replacement.

 

[Greenbeard]

Single payer can't function if people can jump in and out of the insurance pool simply by moving in and out of state.

A citizen of Louisiana getting a $500k medical bill from our current ****ed up system simply moves to California for treatment, and when the system implodes it'll be seen as a failure of single payer and not the ridiculous system that served up a $500k medical bill over simple **** in the first place.

I doubt any state would institute eligibility retroactive to before you were a resident. So a bill incurred in some other state before you moved shouldn't matter.

Anyway, Massachusetts had near-universal coverage (complete with guaranteed issue and subsidized insurance) almost a decade before the rest of the country and as far as I know it wasn't overrun with medical refugees from other states.

 

[Northern Light]

In Canada, if you're a foreigner, though you will certainly get treatment, you will pay for everything. In fact, treating foreigners is big business in Ontario to the point it's potentially problematic: Public hospitals profiting from foreign patients - Toronto | Globalnews.ca

Provinces also have a residency requirement.

I was talking about emergency care, not elective procedures.

 

[Surrealistik]

This is exactly what I said. You're leaning entirely on the notion that we can always rely on price controls to tamp down rising costs if necessary.

Price controls (negotiated with suppliers and providers) and elimination of redundancies and administrative bloat, yes. There's plenty of existing precedent that shows this is exactly what happens; it's not a matter of faith.

In large part, the objective here is to have a weapon to wield against labor--one in eight jobs private sector are in the health sector, so there's plenty of money to be squeezed out of the system by cracking down on them. I'm not convinced forming a government monopsony with that intent is the best way to proceed.

The precedent of pretty much every other first world country would disagree. You seem to be fundamentally making the assumption that the economic benefits of SP UHC would be dwarfed by the reduction of margins in the health and pharma sector, and elimination of insurer middlemen.

I was specifically talking about the amount private payers currently directly spend on drugs and devices.

I'm talking about the net cost and bloat imposed by private payers/insurers on the system, and how the benefits of replacing private payers go beyond the numbers you've noted.

Your single-payer entity is also going to set the prices of the inputs bought by providers? Will it directly set the wages they can pay employees, as well?

The way it typically works in SP is that service prices are negotiated between providers and the government, and providers then bill the SP for services rendered. Wages are derivative of whatever those billings can support.

I'm talking about the United States. What functions are and need to be served? That's a question worth thinking about before tearing up the current system and attempting to plop down a replacement.

Universal coverage at reasonable cost; SP is a proven solution.

I was talking about emergency care, not elective procedures.

You still have to pay for it. The only way to ride SP 'for free' in Canada is by being enrolled in the appropriate provincial health plan with an identifying health card (though certain provinces may allow you to use other identification they can crossreference).

 

[chuckiechan]

Single payer can't be a "let states decide" thing. No State could support it on their own. The whole nation is needed.

In for a penny, in for a pound.

If the state can't afford it, how can the nation? Unless you mean cutting off avenues of escape for citizens and companies.

 

[Greenbeard]

The precedent of pretty much every other first world country would disagree. You seem to be fundamentally making the assumption that the economic benefits of SP UHC would be dwarfed by the reduction of margins in the health and pharma sector, and elimination of insurer middlemen.

I'm not making an assumption, I'm making an observation. We pool our resources through premiums and taxes to reimburse providers for services rendered. That spending--our collective spending--has to cover the costs of those providers, plus provide some degree of margin so they can continue to invest in capacity and innovation.

The idea here is to hand over all responsibility for those reimbursements to a single entity with monopsony power, which then rapidly reduces the total amount of reimbursements its willing to pay out. This, in turn, forces radical disruption among providers who must immediately cut costs drastically or go out of business. So what are those costs?

Two-thirds of spending on personal health care in this country flows directly to hospitals and physician services. According to the federal government, based on mandatory cost reporting by Medicare-participating hospitals, the input costs of a hospital (which our collective spending, financed by our premiums, covers) and their relative contributions look something like this:

What are the costs that make hospitals expensive? Turns out it's people. The time, expertise, and effort of the workforce tends to be a major component of costs. 60-70% of those costs are the expense of giving people paychecks. Everything from clinicians to finance folks to IT staff to janitors. That's why cost control is so difficult; hence the concept of "bending the cost curve" instead of reducing our year-over-year spend.

CMS doesn't collect similar data on physician practices, but MGMA's survey of cost data from thousands of practices tells the same story:

There are two possibilities:

1) Single-payer really would, as you now seem to suggest, simply root around the edges, trimming some margins (primarily of the most easily vilified actors) and displacing some stray admin staff. In which case it won't save nearly as much as billed, and thus requires more revenue to flow to the government to cover its costs. Or,

2) Single-payer will take a serious whack at costs, which means significantly more disruption, displacement, and pain for the workforce than its adherents have thus far been willing to acknowledge.

I suspect in reality (1) would prevail for practical and political reasons, which makes the financing that much more challenging and the rationale for this approach weaker.

 

[brothern]

Single payer can't be a "let states decide" thing. No State could support it on their own. The whole nation is needed.

If the state can't afford it, how can the nation? Unless you mean cutting off avenues of escape for citizens and companies.

California's proposal is wildly inflated in cost as it covers procedures that nearly no other nations with single-payer cover. Services such as day care, hospice services, home care, vision & dental.

If CA wants to be single-payer then that's what would happen. I see many people out of state making trips to CA and conveniently ending up in the ER.

How does conveniently ending up in the ER on a vacation make one a long-term resident of California and thus eligible for the program?

What are the costs that make hospitals expensive? Turns out it's people. The time, expertise, and effort of the workforce tends to be a major component of costs. 60-70% of those costs are the expense of giving people paychecks. Everything from clinicians to finance folks to IT staff to janitors. That's why cost control is so difficult; hence the concept of "bending the cost curve" instead of reducing our year-over-year spend.

Wages make up the largest cost footprint in most all organizations: from my employer, to the US DoD, to the local church. Health care service providers are not abnormal in that wages are massive spend in their annual budget.

Regardless I find it kind of odd that your concern about single-payer is that it's going to lead to some unknown number of administrative staffers being laid off, when the payoffs of single-payer would be, for example, the elimination of medical bankruptcies (half a million per year?) or the reduction of mortality rates for treatable illnesses for individuals who cannot afford healthcare.

 

[brothern]

Additionally in the grand scheme of things - administrative work for the sole purpose of administration adds no value. If I could have exactly one supplier and exactly one customer, and was able to run an organization under those circumstances, I personally would be ecstatic.

Obviously healthcare service providers sweat it because billing less leaves smaller room for margin errors and that's a lot of uncertainty. But a monopsony structure being able to extract value from those providers by eliminating the requirements of having to employ legions of systems, processes, staffers, third-party services, etc. that support the administration of multiple insurers is not something that I think really needs sweating. Especially when the payout is so great, and especially that it involves services that are as prone to market failures as health care is.

 

[Perotista]

FOR THIS POLL, ASSUME A FEDERAL SINGLE PAYER IS NOT AN OPTION.

California likes to point out that it is the 5th largest economy in the world, making it larger than Great Britain, which has a Single Payer Healthcare System.

Should California enact a Single Payer Healthcare System, as has been proposed?

Let each state do as it wishes. If that is what the folks in California want, fine with me.

 

[Greenbeard]

Regardless I find it kind of odd that your concern about single-payer is that it's going to lead to some unknown number of administrative staffers being laid off, when the payoffs of single-payer would be, for example, the elimination of medical bankruptcies (half a million per year?) or the reduction of mortality rates for treatable illnesses for individuals who cannot afford healthcare.

I have no objection to expanding coverage, though that can be done under a multi-payer system--that should be our goal. I object to the notion that it's realistic or feasible to assume that massive real reductions in revenue to care providers is going to happen. As long as our government is answerable to voters, that's not plausible. We could try and move to single-payer but we might as well be open that it costs $3+ trillion (or $400 billion, in the case of CA alone). Because that's what our health system costs. We can't change our starting point, the goal needs to be on improving the trajectory going forward.

Frankly, I don't understand the obsession with single-payer. Universal multi-payer systems are far more common throughout the world than anything resembling what CA was flirting with. We already have a multi-payer system--barring a WWII-esque catastrophe that allows us to hit the reset button and start from scratch, we'll need to build on what we have in place here. Which we've already started to do.

 

[Lovebug]

Let each state do as it wishes. If that is what the folks in California want, fine with me.

Wouldn't that create a new problem? If you (general) work in KY and have a job prospect in NV, get sick in between jobs, you are really in trouble if states did what they wanted and didn't have the preexisting condition clause.