Should California Pass Single Payer?

[chuckiechan]

Where is the "if they want to. It is up to them" option?

More accurately: "if the public unions who run the electoral process want it, then yes."

They are expected to have a carve-out in exchange for their support.

 

[American]

Where is the "if they want to. It is up to them" option?

The Peoples' Republic of California isn't allowed that option.

 

[wellwisher]

I think it should be tried as an experiment, but with the condition the Fed cannot bail them out by law, even if the system collapses. Everyone who uses the system will need to sign a waiver and be liable for their decision. If need be, California will need to liquidate and sell assets to raise money. It can sell protected land and mineral rights to raise money to keep the system afloat. Or it can over tax business and drive that out.

The Democrats think with their hearts, but lack common sense solutions. The result often becomes money pit solutions, too big to fail. Then everyone else is extort with emotions for a bailout. The law will allow them to fail, no matter how big they get, without any induced guilt less they be taken to court for breech of contract. Then they will need to liquidate even more to cover fines.

 

[chuckiechan]

More accurately: "if the public unions who run the electoral process want it, then yes."

They are expected to have a carve-out in exchange for their support.

For background, the California nurses association wants the same political power the rest of the public unions have allowing them their cut of the budget pie. It really is an idea going nowhere for two reasons, one it's unaffordable, two the teachers union is against it without carve outs which they won't get.

And obviously, citizens don't want to be relegated to Medi-Cal status. (Welfare), should anyone care to explain it to the,

 

[Perotista]

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.

Each state has its own insurance commissioner or the like. Let California go to single payer or not, up to them. The rest of the 49 states would be exactly what it is now. The question then becomes if from Georgia and visiting California, would California take care of you if you became sick? You're not in their system or paid the California state taxes to get into their system. I would imagine the hospitals and doctors would still accept health insurance from out of state.

If not, weigh that when you decide to go on vacation. People travel all over the world really not knowing if the country they are visiting will accept their health insurance if they get sick. I see no difference here. Let California do what is wishes. I'd be interested to see how it works out. The test bed, the lab, the guinea pig so to speak.

 

[Redress]

The Peoples' Republic of California isn't allowed that option.

I did not know cpwill was a republic...

 

[Northern Light]

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.



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 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.



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.



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




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).

You can't force visitors to pay for it if they're leaving the country, and the law forbids the ER from refusing serious cases.

 

[Northern Light]

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?

It doesn't.

For the 10th time already: hospitals can't refuse serious cases, so who is going to pay for that? All people have to do is wait until their conditions become bad enough and then go visit CA for ER care, on their dime.

 

[Surrealistik]

There are two possibilities:..

That sure is a lot of words and graphs which essentially fail to prove your case: namely that the collective benefits of UHC, economically and otherwise, are outweighed by the disruption to healthcare as it exists (which itself hasn't been meaningfully quantified or assessed).

No one is denying labour as a majoritarian expense in healthcare as it exists.

What is being disputed is your assertion that the status quo and the economic well-being of those in the health, pharma and insurer industries, which yields a cost of care that's among the highest on the planet while failing to cover a significant percentage of the population, outweights the collective social and even long term economic good of UHC SP. With this I completely disagree. Though I obviously cannot prove beyond all doubt that this will be the case as I cannot peer into the future, the existing precedence of other countries suggests I'm probably right.

As for your two other assertions:

#1: This is not my argument, nor my suggestion. I certainly don't shy away from necessary disruption and the creative destruction of inadequate paradigms in California healthcare. Further, administrative expenses are _not_ some minor component of overall health costs as was demonstrated earlier. By the way, the California state estimate assumes little to no savings so there likely won't be many surprises even if SP tackled only fringe expenses.

#2: Yes, SP certainly will take a serious whack at costs if it is properly implemented. There will be casualties. Health sector wages are likely to go down; hospital staff will become leaner; healthcare insurers will be routed or repurposed into secondary modes of coverage. These are all acceptable costs when one considers the delivery of cost effective healthcare to everyone in state, and all the secondary offshoot benefits of that to the economy and standard of living. That tradeoff is very much worth it. When you have several industries that, as stated, have gotten fat off exploitation off both the lack of elasticity for healthcare demand, and the lack of any effective price moderating force, the destruction of those accumulated inefficiencies, including excess labour and salary and entire administrative layers, is going to have some side effects.

Personally, I wouldn't mind in a phased in decrement of prices over time if only to minimize the short term shock and believe that's probably advisable, but that isn't mandatory.

...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...

Except other countries have and did. Why should America be any different?

Given the substantial majority support for SP in California despite the price tag (which is really $200-106 billion, depending on who's doing the cost assessment after medicare/medicaid and other such payouts), the voters have been actually quite clear on the fact that they overwhelmingly support singlepayer; it is precisely because government is supposed to be answerable to voters that it's plausible. Big pharma, providers and insurers certainly aren't majoritarian voters so this argument is extremely weak. What they are however is powerful donors; obviously Rendon has other ideas about his accountability to constituents, preferring instead to placate their interests instead.

Frankly, I don't understand the obsession with single-payer.

Maybe because it's been repeatedly demonstrated to yield comparable to superior outcomes while being vastly more efficient and cost effective with more comprehensive coverage?

How the U.S. Health Care System Compares Internationally - The Commonwealth Fund

Bottom line:

A: SP is affordable no matter whose estimates you're going with, though yes, substantial tax increases will be required. That's fine though according to the people of CA; they're evidently willing to pay, even after being confronted with a 15% payroll tax.
B: Guaranteeing comprehensive coverage for all of CA, including millions of uninsured, is more important than guaranteeing the benefits and salaries of a small minority of people working in health, pharma and insurance that have been collectively profiting off a bloated system.
C: Per the precedence of other countries, adverse effects of health care healthcare disruption long term is unlikely; further long term health outcomes are likely to be better.
D: SP is extremely popular; implementation is politically viable. If there _is_ a substantive political pushback, it is from donors and industry interests, _not_ the electorate.

 

[Surrealistik]

You can't force visitors to pay for it if they're leaving the country, and the law forbids the ER from refusing serious cases.

#1: Though I'm not familiar with how far provinces go to collect medical bills, foreigners certainly are billed for emergency services. Further, provincial healthcare systems tend to actually _make_ money in net from foreign patients.

#2: Leaving California's borders doesn't mean you're impervious to collections from the state of California; you will go just as bankrupt for using their services in this way as you would in any other state.

#3: Monetary losses from foreigners seeking emergency treatment in Canada then skipping out on the bill has never been reported as an issue to my knowledge so this is in practice a minor issue if one at all. What _was_ an issue once upon a time was rampant health fraud from Americans coming over the border to get treatment with falsified or borrowed health cards until we improved our health identification.

 

[American]

I did not know cpwill was a republic...

Well he is for the duration of this thread.

 

[Northern Light]

#1: Though I'm not familiar with how far provinces go to collect medical bills, foreigners certainly are billed for emergency services. Further, provincial healthcare systems tend to actually _make_ money in net from foreign patients.

I need to shift the goal posts a bit here. What I'm talking about is actually the obligation of ERs to treat people regardless if they can afford treatment or not, which is what the single payer system affords hospitals to do. Payment comes later. In most U.S. states, even ER care is two-tiered. They'll save your life but that's it, and so you end up in a revolving door of coming to the ER whenever you're in critical condition but getting no supplementary care. Under single-payer, all care is provided and the bill comes later. Virtually all single-payer countries work this way, regardless if they actually end up seeing your money or not.

If I get into a car accident in CA as a non-resident and I need urgent care, the single payer system would have to absorb it if I can't pay it. If CA instead makes hospitals absorb the debt (as in other states), then it's still a two-tiered system and not single-payer. Do you understand? As hospitals accumulate debt from non-residents, they will begin the same cost cutting measures internally that CA is trying to use single-payer to correct in the first place.

#2: Leaving California's borders doesn't mean you're impervious to collections from the state of California; you will go just as bankrupt for using their services in this way as you would in any other state.

In relation to my comment above... if under single-payer you get free treatment (treat first, bill later), then that's not really a problem. People will go bankrupt rather than stay sick. It's already one of the biggest liabilities in the U.S. So how will CA compensate for this with a limited State budget (no federal help)?

#3: Monetary losses from foreigners seeking emergency treatment in Canada then skipping out on the bill has never been reported as an issue to my knowledge so this is in practice a minor issue if one at all.

Most foreigners come to Canada for treatment because the single-payer system has greatly reduced cost-per-treatment, unlike in the U.S. where health care is about profit. If CA plans to maintain its bloated HMO system under single-payer, then it won't survive. It's not enough to just implement single-payer, you actually have to implement cost cutting strategies. CA is not known for doing so in most of its social systems. How will it contend with the bloated HMOs and drug companies, all of whom are entitled to obscene profits under Federal law and whose products are grossly overvalued? In fact, is there any health care or drug company who would even be incentivized to work with CA when they can just transfer their holdings to other states where they can continue making obscene profits? CA can't stand alone.

It's not a widely known issue because Canada ends up absorbing the unpaid bill. Same with student loans (after 5 years). The U.S. has no such contingency. People either go bankrupt or the government has a long-term unpaid liability, both of which are economic burdens.

What Canada can do is tie your bill to your passport so that if you ever try to enter Canada again you will be denied entry unless you pay your outstanding healthcare bill. But Canada is a country with enforceable borders, CA isn't. For desperate people in places with no health care, the trip is worth it.

Having one state in the U.S. provide single-payer while everywhere else is private or under the defunct ACA is basically tossing meat into a shark tank. It's going to blow up in CA's face, mark my words.

 

[Surrealistik]

I need to shift the goal posts a bit here...

Yes I'm aware, and yes, the state will absorb the initial cost; this isn't being disputed.

The point is that non-residents do get charged, and that I don't expect the amount of non-payment to be higher than it is elsewhere, especially if there is a separate tier of billing for non-residents (i.e. hospital bills at the usual rate, government charges a premium on top) so they're not incentivized to crash California ERs explicitly for cheaper treatment (which is where the ER exploitation line of argument runs into a bit of a paradox; if they just plan to stiff the health care system and eat bankruptcy, they don't care about cost; if they do, they're probably going to pay their bill, or at least they intend to, which makes the risk of stiffing minimal).

Most foreigners come to Canada for treatment because the single-payer system has greatly reduced cost-per-treatment, unlike in the U.S. where health care is about profit. If CA plans to maintain its bloated HMO system under single-payer, then it won't survive. It's not enough to just implement single-payer, you actually have to implement cost cutting strategies. CA is not known for doing so in most of its social systems. How will it contend with the bloated HMOs and drug companies, all of whom are entitled to obscene profits under Federal law and whose products are grossly overvalued? In fact, is there any health care or drug company who would even be incentivized to work with CA when they can just transfer their holdings to other states where they can continue making obscene profits? CA can't stand alone...

A cost assessment that effectively assumes no real cost savings has been forwarded by the state with a price tag of $400 billion, or $200 billion in real, increased spending after deducting medicare and so on. Steep yes, but it can be financed in a number of ways which have been proposed; this is pretty much a worst case scenario; bad but affordable with substantial tax increases. In practice, there probably will be substantial savings, making the real increase in spending roughly around $100 billion ( Study: Single-payer plan would save California $37 billion per year ).

I agree that there's certainly the risk of political donor/industry interference and sabotage when it comes to negotiations, but that aside, at the end of the day, suppliers and provider companies are simply not going to want to discontinue selling into the most economically powerful and populated state in the union and leave money on the table; it's just not going to happen; it's really a question of how much costs can and will be reduced.

As for Canada's case, it's not a widely known issue because it's not an issue (unless you have some evidence specifying otherwise). Again, American defrauding of the Canadian healthcare system in the 90s was a known and serious issue and it got airtime and press as a result. If people coming to Canada specifically to crash our ERs and stiff the government en masse was actually a systemic problem it would most certainly get attention. If you have some proof to the contrary, I am legitimately very interested in seeing it.

That having been said, as stated above, I don't see why people would be specifically motivated to come to California to stiff the system on the basis of cost, because if cost is a factor, odds are they're going to repay their debt, and if it isn't, they can crash any ER anywhere. Either way I'm certainly in favour of having medical treatment for non-residents be expensive enough as to sufficiently discourage capacity choking medical tourism, which might leaves state residents unable to get timely care as was a problem in Canada (though it did make our healthcare system some significant $$$ on the plus side).

Having one state in the U.S. provide single-payer while everywhere else is private or under the defunct ACA is basically tossing meat into a shark tank. It's going to blow up in CA's face, mark my words.

The risk exists to be certain, but it's really a question of how SP is implemented, not a straight up inevitability. If properly structured with effective price negotiation, long residence requirements and strong IDs it should be successful.

 

[brothern]

It doesn't. For the 10th time already: hospitals can't refuse serious cases, so who is going to pay for that? All people have to do is wait until their conditions become bad enough and then go visit CA for ER care, on their dime.

So your argument is that California literally does not know who its residents are and therefore would reimburse literally anyone's medical bills who showed up at a California hospital?

 

[Northern Light]

So your argument is that California literally does not know who its residents are and therefore would reimburse literally anyone's medical bills who showed up at a California hospital?

NO. That is NOT what I'm saying. Please re-read my posts.

 

[brothern]

If I get into a car accident in CA as a non-resident and I need urgent care, the single payer system would have to absorb it if I can't pay it. If CA instead makes hospitals absorb the debt (as in other states), then it's still a two-tiered system and not single-payer. Do you understand?

Yes - that happens today without the single-payer system. If I as an Illinois resident needs emergency care in California today, the hospital cannot refuse service. It has to provide care. The hospital then bills either my insurance or me personally -- if I have no insurance -- to recover the costs of service.

Single-payer does not change that situation, and I'm totally confused as to why you think that it would. If the individual is an Illinois resident, the hospital would still bill my insurance or me personally. If the individual was a California resident, then the hospital would bill the state.

Why do you think the hospital or the state would be clueless to the fact that I'm a non-resident?

 

[Greenbeard]

#1: This is not my argument, nor my suggestion. I certainly don't shy away from necessary disruption and the creative destruction of inadequate paradigms in California healthcare. Further, administrative expenses are _not_ some minor component of overall health costs as was demonstrated earlier. By the way, the California state estimate assumes little to no savings so there likely won't be many surprises even if SP tackled only fringe expenses.

This is what I'm talking about. You embrace "necessary disruption and creative destruction" and then point out that it's unlikely that would actually happen in practice for practical reasons. Little to no actual savings. I agree--with one of your incompatible points, anyway! Which means we need to come up with a lot of new revenue to convert all existing health care expenditures to government spending. Which virtually no one wants to do.

#2: ... including excess labour and salary and entire administrative layers, is going to have some side effects.

I'm still unclear why you think it's in the government's purview to identify "excess labor" and eliminate it. I'm sympathetic to the idea that government should try to do good. I like public policy! I've worked in it my whole adult life in some fashion. But this idea that it's the public sector's role to determine what people should make, how many should work in an industry, how much the nation should spend on a given set of services and then form a monopsony to enforce those arbitrary decisions is alarming to me. And that's because I'm spent a lot of time around folks who are exceptionally active in and knowledgeable about health policy, and yet I wouldn't trust any of them to make the determination of what the "right" quantity of any of those things should be.

Single-payer is most attractive when the universal coverage and administrative simplification aspects are trumpeted. Less so when the goal of taking a financial chainsaw to a sector of the economy out of spite is mentioned.

The rightful role of policy here is to create a system in which people can tell you how much is enough. You can bring up the low-to-middle-income people to give them a degree of purchasing parity so that their feet vote as well as anyone else's, but you still let people vote with their feet. I'm a big proponent of choice architecture and "nudging," so to speak, so I'm not suggesting that policy shouldn't etch some trails into the terrain so that when they vote with their feet they know which way to go to send the signals they want to send. But to try to make those determinations for others--or the entire economy--is a mistake, no matter how well-intentioned.

Except other countries have and did. Why should America be any different?

I'm not going to pretend to be a historian of the health care systems of systems other than the U.S. But I believe most made the transition to their current systems in the immediate aftermath of WWII.

None, as far as I know, have done anything even remotely like what SP advocates suggest: that is, purposefully cutting their health sector down to whatever size they've decided it should be, particularly when that sector is (or is on the verge of becoming) the single largest employment sector in the economy. In other words, I'm not aware of another nation deciding their health care sector was too big and setting out to drastically shrink it. In the most recent convert to SP, Taiwan, health spending as a percentage of GDP grew after the transition so it's not a comparable situation.

Suggesting that the transition of 1940s medicine in post-war Europe to what you're describing is in any sense comparable to what it would mean to do the same in the United States in 2017 is insanely disingenuous.

Given the substantial majority support for SP in California despite the price tag (which is really $200-106 billion, depending on who's doing the cost assessment after medicare/medicaid and other such payouts), the voters have been actually quite clear on the fact that they overwhelmingly support singlepayer; it is precisely because government is supposed to be answerable to voters that it's plausible.

Polling from earlier this year suggests Californians are no different from anyone else: single-payer is popular with them unless it raises their taxes.

Single-payer polled well in Colorado and Vermont at one time, too. Maybe it still does. The problem doesn't come when you ask someone a hypothetical question, it comes when the rubber meets the road. If you don't consider any potential downsides, everyone loves it--I love it!

 

[Surrealistik]

This is what I'm talking about...

Actually no, I pointed out no such thing though I appreciate your naked attempt to incorrectly and disingenuously frame my views in support of your own; I think that if SP is going to go ahead it should and probably will result in considerable cost savings, which will have significant impacts on providers and suppliers.

I think it's likely that special interests will try to sabotage negotiations in their favour, of course; with so much pressure and so many constituents watching as historic legislation is crafted, I have my doubts as to whether they'll get away with it this time.

I'm still unclear why you think it's in the government's purview to identify "excess labor" and eliminate it...

Except I don't believe that identifying and eliminating 'excess labour' is not the purview of government so much as it is ensuring universal access to healthcare; eliminating the considerable bloat and inefficiencies that acts as obstacles to this end just so happens to be a necessary part of that function and onus.

Status quo apologists like you have had more than a century to get your **** together and create a system that guarantees cost effective access to health care and you have failed miserably and continue to fail miserably. Spare me your concern for criminally inefficient industry sectors that exploit what is a wild west in pricing for essential goods with inelastic demand. You keep claiming that SP is a mistake, but the actual facts and precedent endlessly and relentlessly contradict you; what we see is that where deployed, as stated and demonstrated, it delivers comparable or better outcomes to more people for much less money. That is a fact. The freedom to essentially gouge Americans, which you seem to stand for per your adamantly stated positions, whether for drugs, labour, insurance, should not be prized over their access to health care, and essential good, at a price that's reasonable. Yes, the government should get involved on a substantial level if that's what it takes to realize such superior results for the vast majority in the case of an essential, inelastic good.

I'm not going to pretend to be a historian of the health care systems of systems other than the U.S. But I believe most made the transition to their current systems in the immediate aftermath of WWII...

...Suggesting that the transition of 1940s medicine in post-war Europe to what you're describing is in any sense comparable to what it would mean to do the same in the United States in 2017 is insanely disingenuous.

Wow.

See, it's obviously not that these countries thought their health care sector was too big, so much as that they felt compelled to guarantee equitable healthcare access to all citizens, and that an essential good with little demand elasticity should feature public intervention. In the case of the States, a considerable _bonus_ is that the staggering inefficiency of the sector, and related industries will be streamlined.

By the way, speaking of insanely disingenuous, that would pretty much describe taking the solitary example of a tiny city state island like Taiwan and holding it up as some kind of definitive proof in favour of your argument, but hey, before you embarrass yourself further, check out this article that goes into depth about Taiwan and how SP has actually saved it money:

https://cdn1.sph.harvard.edu/wp-con...l_insurance_make_health_care_unaffordable.pdf

By the way, Australia introduced SP in 1984. Spain? 1963 with universality in 86, and they're far from the only ones that drafted SP systems significantly after WW2 passed.

Polling from earlier this year suggests Californians are no different from anyone else: single-payer is popular with them unless it raises their taxes... ...I love it!

No you don't; I mean **** man, your biggest argument against it wasn't the cost so much as the impact it would have on insurers, provider and supplier margins, then trying to humanize it by talking about it in terms of jobs, as if falling salaries among their industries and layoffs of even tens of thousands, somehow outweighs the healthcare access of millions of Americans. Please.

As for SP polling, 70% of CA residents support it, and 58% support it after hearing opposition arguments: https://www.commondreams.org/newswi...-70-californians-support-ca-medicare-all-bill

Even if I assume the poll mentioned in the LA times is correct though, what truly matters is whether support exceeds opposition (which it didn't mention).

 

[Quazimodo]

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?

Absolutely! It's California. What could possibly go wrong.