[HN Gopher] NY Senate Bill S5474 proposing a universal single pa...
___________________________________________________________________
NY Senate Bill S5474 proposing a universal single payer health plan
for NYers
Author : KoftaBob
Score : 263 points
Date : 2022-05-09 20:18 UTC (2 hours ago)
(HTM) web link (www.nysenate.gov)
(TXT) w3m dump (www.nysenate.gov)
| GiorgioG wrote:
| There's too many jobs at stake for existing health insurers. This
| will go exactly nowhere.
| TuringNYC wrote:
| It would be great if they could handling things already
| successfully resolved in other places, like Balance Billing
| https://en.wikipedia.org/wiki/Balance_billing#United_States
|
| When I was with a Virginia employer, it was WYSIWYG on billing.
| In NY, you never know since there is the co-pay, and then there
| is the surprise 2nd bill that comes in the mail. It is a solved
| problem, not sure why such obvious solved problems cannot be
| implemented in NY.
| ceejayoz wrote:
| Balance billing was banned federally.
| https://www.dfs.ny.gov/consumers/health_insurance/surprise_m...
| xyst wrote:
| If only we can get the other 48 states to have a single payer
| health plan initiative or adopt a nationalized single payer
| health care system.
|
| Health care should not be limited to just living in CA or NY or
| the rich.
|
| side note: this site for tracking bills at the state level is
| kind of nice. Wish other states had this. This is what I have to
| deal with in TX
|
| https://capitol.texas.gov/MnuLegislation.aspx
| jimmygrapes wrote:
| I wish all advocates for single payer systems could experience
| the Veterans Health Affairs (plus or minus the "Community Care"
| system) just to see what it they are in for. Give it a trial
| period of 2 years. Have fun.
| VWWHFSfQ wrote:
| If this is anything like the ACA then the vast majority of New
| Yorkers will end up paying twice for insurance. Once in taxes to
| subsidize the single-payer marketplace, and then again for their
| own employer-based insurance. Have to start somewhere though, I
| guess.
| baggy_trough wrote:
| If doing something is going to make the situation worse, it is
| better to do nothing instead.
| irrational wrote:
| It may only appear to make things worse. Sometimes you have
| to take drastic measures, like amputating a limb, to make
| progress on saving people.
| jimbob45 wrote:
| You seem to believe employees wouldn't be able to opt out of
| their own employer-based insurance. Why is that?
| kevindong wrote:
| From the summary of the bill:
|
| > Private insurance that duplicates benefits offered under
| New York Health could not be offered to New York residents.
|
| ---
|
| My interpretation of that is that private insurance (which
| includes employer-based insurance) would be banned.
| a_t48 wrote:
| For the employee it doesn't matter. Either I keep my existing
| insurance or I opt out and take the state provided one, but I
| don't get any more money the money I'm saving the company.
| paulmd wrote:
| Yeah, the penalty for ACA non-compliance is zero at this
| point, so I think they could just opt-out entirely without
| cost, right?
|
| I looked at it last year in terms of whether I'd need to pay
| for COBRA to cover the tax penalty and... nope. You can
| retroactively opt into COBRA for 90 days after the fact
| (iirc, check this yourself before using), so you can job hop
| and then if you happen to smash every bone in your body
| during that one week then just sign up for retroactive
| coverage.
| jjoonathan wrote:
| Nooo! Public option is not a half measure, it's a ~zero
| measure.
|
| Single payer >>> public option. Public option is really easy to
| kill, just kneecap it any of a hundred ways, call it a failure,
| and then sell killing it as a tax break. It has the staying
| power of a cobweb on a car wheel. Failure is inevitable and it
| won't just be dead, it'll be held up for decades as proof that
| our government is uniquely incapable of doing insurance.
|
| Contrast to single payer, which is hard to kill because people
| are yes paying a tax but also seeing a benefit and seeing a
| benefit that they didn't have before (healthcare doesn't go
| away if they lose employment). It doesn't suffer from adverse
| selection, it isn't an easy target for kneecapping, and it has
| a chance in hell of actually working.
| VWWHFSfQ wrote:
| I would advocate for Medicare-for-all but that isn't going to
| happen in my lifetime. So if states want to try their own
| single-payer systems then go for it. But I'm still going to
| grumble if I see (yet another) big number taken out of my
| paychecks for it.
| tsol wrote:
| How/why is failure inevitable?
|
| >Contrast to single payer, which is hard to kill because
| people are yes paying a tax but also seeing a benefit and
| seeing a benefit that they didn't have before
|
| Isn't that true for a public option as well?
| upbeat_general wrote:
| No because it is a public _option_. Thus not everyone uses
| it.
| afarrell wrote:
| There are UK employers who have offer health insurance as a
| benefit on top of the healthcare available from the NHS.
| There's not much point to it, but it is available.
| przemub wrote:
| I have such an arrangement and it's extremely useful.
| techsin101 wrote:
| I pay 100k+ in taxes, if this happens I'll be actually happy even
| more.
| susanasj wrote:
| it appears that this bill does not actually deal with the funding
| mechanisms for single payer, which will undoubtedly be
| contentious. From the Campaign for New York Health:
|
| > this legislation can be passed outside of the budget as a
| standalone bill - the #NYHealthAct is intentionally written to
| first pass on human rights principles - that care should be
| equitable and available to all. Then we pass the funding
| mechanisms in the following session - that is when NYHA becomes
| part of the budget battle) - begins implementation of systemic
| long-term change to guarantee universal, comprehensive, single-
| payer healthcare to everyone who lives or works in New York
|
| from: https://www.nyhcampaign.org/
| [deleted]
| colechristensen wrote:
| Seems a bit pointless to pass a feel good bill that will cost
| billions and ignore the whole money situation hoping to solve
| it.
| starkd wrote:
| Elections are coming up.
| mostertoaster wrote:
| Crazy healthcare costs are the result of government intervention
| back in the 30s, and I'm doubtful they will actually be able to
| lower overall costs. Single payer has the advantage of being able
| to negotiate the costs for a much larger volume, but my guess it
| won't be enough to cover the cost of bureaucrats to administer
| it.
|
| Still I'm all for them trying it, if it fails miserably and the
| "free" healthcare leads to never being able to see the doctor and
| costing more, then everyone else can stop trying to emulate it.
| If it succeeds and actually saves money and still provides good
| healthcare, then we might be able to try it at a larger scale.
| Certhas wrote:
| The US pays vastly more to administer it's health care than any
| other OECD country. Your assertion that the cost of government
| bureaucracy should exceed the cost of private markets at this
| task is emphatically not backed by data.
|
| A good place to check your assumptions on these kind of basic
| things is the OECD data. Healthcare is here:
|
| USA 1.4% of GDP on governance of healthcare Germany 0.5%
| (competing public insurance schemes) UK 0.2% (single payer)
|
| US style healthcare is an ideologically driven luxury.
| aserdf wrote:
| it will be interesting to watch NY (and/or CA) put something like
| this in place and observe from afar. i strongly feel that states
| should be much more aggressive running policy experiments if
| their constituents desire them, and at the national level we all
| get some benefit of seeing how things turn out in real time.
|
| all that said, assuming there is some tangible tax increase, NYC
| high earners are going to be knocking on the door of 60% combined
| rates (city, state, federal). tax avoidance and/or relocation
| services are going to be booming if so.
| zjaffee wrote:
| NY should pay for single payer in part by raising real estate
| taxes, it's the only clear way the state has to avoid capital
| flight in the way you're describing here.
|
| This said, a big thing NY benefits from is that a lot of people
| work in NY state temporarily as consultants in addition to the
| bridge and tunnel crowd that come in from NJ and CT, this gives
| them a much larger tax base than the population living there
| brings in on its own.
| hersko wrote:
| I live in NY and pay >$18k a year in property tax for a small
| house. Real estate taxes are high enough.
| kevin_thibedeau wrote:
| They are offensively low for multi-million dollar buildings
| in NYC. Cut some slack for owner occupiers who had the
| assessed value skyrocket on them. Tax everybody else
| fairly.
| bradleyjg wrote:
| A part of the reason is idiotic programs like 421a
| debacle wrote:
| New York is losing population at a breakneck pace. Our
| government is to blame.
|
| I am for single payer to some extent, but if done poorly
| medical staff (who are already leaving due to pandemic
| policies) will just pick up and leave.
|
| We recently expanded the privileges of nurse practitioners
| which is great, but two large nursing unions are less than 60
| days away from striking.
| joshstrange wrote:
| Citation needed. Every population graph I can find show a
| small decline over the last few years but it's still above
| 2000 and they've had population dips before (1970-1980) that
| then recovered.
|
| This comment reads like my in-laws who always talk about how
| "people can't get out of CA fast enough", um the population
| numbers say otherwise.
| pirate787 wrote:
| "A smaller Empire State: New York continues to lead nation
| in population decline"
|
| https://www.democratandchronicle.com/story/news/politics/al
| b...
|
| The population flight is primarily for US-born residents,
| which is what happened in CA as well.
| timtom39 wrote:
| CA is losing population:
| https://www.sfchronicle.com/bayarea/article/Bay-Area-
| countie... It isn't crazy fast but it is happening. We will
| see if the trend holds...
| UnpossibleJim wrote:
| How much of this do you think comes from the Bay Area and
| Los Angeles housing costs and the ability to remote work
| in the last couple of years (which seems to be coming to
| an end... possibly) and how much do you think is because
| of policy and city deterioration which has been
| publicized?
|
| I can't speak for CA but I see parallels in Seattle,
| though there's only movement to other cities within other
| WA cities (mainly the east side).
| majormajor wrote:
| The common refrain is very Yogi-Berra-like, "nobody lives
| there anymore, it's too crowded."
|
| Few people on the right want to connect things like
| rising homelessness -> rising rents and property values
| in the same period -> an influx of high paying jobs.
| There aren't concrete policy proposals given to fix those
| things given the circumstances of the last decade, just
| finger-pointing at whatever particularly policy someone
| doesn't like. The amount of gymnastics done to blame
| anything other than "importing a bunch of high-earners
| and/or wealthy people has unintended consequences" is
| high. E.g., pointing to pre-Covid out-migration overall
| numbers while ignoring net in-migration within the US for
| earners over 100K/yr. (I haven't seen if this has changed
| post-Covid, it wouldn't suprise me if it has, but one
| would want to keep an eye on it over the next two years
| as policies around WFH shift, of course.)
| Mountain_Skies wrote:
| Why would you even mention "the right" in any
| conversation involving the governance of San Francisco?
| What level of control does a party need before accepting
| responsibility for their governing instead of looking for
| an exiled boogeyman to blame?
| dwighttk wrote:
| NY had been holding steady at about 6.5% of the US
| population since around 2010, but recently dipped just
| below 6%
|
| https://united-states.reaproject.org/analysis/comparative-
| tr...
| astura wrote:
| Doesn't sound like a "breakneck pace."
| bawolff wrote:
| This is how it worked in canada.
|
| Saskatchewan decided they wanted single payer health care so
| they did it. About a decade later the federal gov made it
| national.
| beebmam wrote:
| That's 60% _marginal_ rates.
|
| Last year I paid 17% of my total income in taxes.
| revnode wrote:
| You paid much more than that. A substantial part of your rent
| is property taxes. I also doubt you included sales taxes in
| that number. Then there's more esoteric stuff like tariffs,
| etc
| countvonbalzac wrote:
| Rent is not tax, what an absurd comment.
| NovemberWhiskey wrote:
| If you're renting, your landlord is paying property tax
| and passing it on to you.
| kevin_thibedeau wrote:
| Some states let you deduct a portion of rent in place of
| property tax.
| jonathankoren wrote:
| By that logic, no one pays taxes except consumers.
| kingrazor wrote:
| Isn't this basically the case at the end of the day? Just
| about everything seems to eventually get passed on to the
| consumer.
| prepend wrote:
| I mean you're sort of right. There's no such thing as a
| free lunch. So stuff is all ultimately paid by the
| consumer since that's the end of the line.
|
| There's really no way to increase taxes without impacting
| consumers. Unless you try to limit rents, but then you
| have other problems with people not wanting to invest in
| apartment buildings.
| mypalmike wrote:
| One of many counter examples: Corporations holding
| investments with capital gains aren't sourcing tax
| payments from consumers.
|
| Pass-through taxes exist though, yes.
| [deleted]
| Manuel_D wrote:
| The point is, the apartment owner pays property tax and
| collect rent from tenants to pay for that. If property
| taxes go up, property owners raise rents to compensate.
| So the tenants are paying the property tax, albeit
| indirectly.
| strombofulous wrote:
| If the tenants will pay and it doesn't break any rules,
| why not raise rent before taxes go up and pocket the
| extra? (serious question)
| neon_electro wrote:
| This happens all the time. Deciding whether a raised rent
| price is justification for moving out is a complicated
| and personal process and yet it fuels all of the response
| to landlords that do this.
|
| Also, 1-year leases are typical in the U.S. (at least
| Philly/NYC northeast U.S.), so from that contractual
| perspective, your rent can go up every year and that's
| totally legal.
| winstonewert wrote:
| If one landlord raises the rent, this will tend to make
| renters go to other landlords who are not raising the
| rent. But if the taxes are increased on all the
| landlords, they will likely all raise their rents
| together and renters can't simply go to another landlord
| who isn't raising the rent to avoid the increase.
|
| Its actually much more complicated then that, depending
| on factors such as the propensity of landlords to cease
| renting out units if their profit decreases, the
| propensity of renters to shift to smaller dwellings in
| the face of rent increases, etc.
| dwallin wrote:
| Landlords are also competing with each other and tenants
| have limits based on what they can actually afford to
| pay. At some point they can be forced to move out of the
| city to a lower cost of living location, dropping demand.
| In fact it's entirely possible for a significant increase
| in tax rates to make rental units a poor investment,
| causing housing prices to plummet and rents to drop.
|
| Your mistake is assuming that people who bought up
| housing stock are guaranteed future profit on their
| speculative investment.
| Manuel_D wrote:
| > In fact it's entirely possible for a significant
| increase in tax rates to make rental units a poor
| investment, causing housing prices to plummet and rents
| to drop.
|
| How does this logic work? Building apartments becomes a
| bad investment. Then developers don't build apartments.
| And somehow constrained supply is supposed to result in
| lower prices?
| disillusioned wrote:
| Step 1) Raise taxes on rental properties astronomically.
|
| Step 2) Force out investor class and/or repossess
| properties out of tax adjudication.
|
| Step 3) Public housing!
| listless wrote:
| I'm a landlord and yes it is. My taxes doubled last year
| because of the stupid housing bubble and so we had to
| raise rent as well. Gotta make a profit here for this
| investment to be worthwhile.
| AnIdiotOnTheNet wrote:
| Maybe if people didn't buy property they don't live in as
| an investment then things like the stupid housing bubble
| might not happen in the first place.
|
| Personally I think owning a residence you don't actually
| live in should just straight up be illegal, but I'm
| admittedly pretty radical about parts of the system that
| seem to exist solely to make the rich richer.
| rabuse wrote:
| If government reduced their hold on zoning restrictions
| and allowed for more properties to be built, we wouldn't
| be in this mess. Supply and demand.
| RHSeeger wrote:
| So, if I am going to live in an area for a year... I
| should be required to purchase a house, including all the
| money, time, and effort that involves? I would hate to
| live in a world where that was the case.
|
| I have both owned and rented at different points in my
| life. There have been times where renting was a better
| choice for me, for a variety of reasons. I am glad that
| renting is an option.
| thebigman433 wrote:
| > My taxes doubled last year because of the stupid
| housing bubble and so we had to raise rent as well. Gotta
| make a profit here for this investment to be worthwhile
|
| Surely you see stuff like this is part of what is driving
| this very bubble?
| daenz wrote:
| "rent" != "a substantial part of rent"
| thebean11 wrote:
| NY has low property taxes compared to most no-income-tax
| states
| RHSeeger wrote:
| NY's property taxes are among the highest in the nation
| (top 10).
| vlan0 wrote:
| Where is that?
|
| My parents lived in North County and paid 13k+ a year on
| a $350k house. Their current place in Tampa is about 400k
| and the taxes are less than half of what they were in NY.
| Maybe Florida is a special case?
| lotsofpulp wrote:
| WA is also lower than NY. I have a few properties, and I
| would say property tax is 0.75% to 1% of market value,
| max.
| thebean11 wrote:
| I'm basing this off of apartments in NYC. I often see
| ~$600k co-cops with $800 monthly co op fees (of which
| half is maintenance half is taxes). That seems low to me
| compared with similarly priced homes elsewhere.
| [deleted]
| dwallin wrote:
| You can't just assume tax increases directly lead to
| increased 1:1 consumer prices, that's not how supply and
| demand works.
| revnode wrote:
| Where did I assume that?
| dwallin wrote:
| - A substantial part of your rent is property taxes.
|
| Without detailed analysis there's no way to know if this
| is true, or how true it is. It is entirely possible for
| an increase in taxes to lead to no increase in end prices
| or even a drop in rent prices. It's a complex system.
| akimball wrote:
| All property taxes are paid from rents unless the
| landlord is operating at a loss.
| revnode wrote:
| I didn't say anything about increases in taxes. You added
| that. I also didn't say anything about increases or drops
| in rent. You added that again.
| ABCLAW wrote:
| >A substantial part of your rent is property taxes.
|
| Here.
|
| Without determining elasticity, it's impossible to
| determine how much of that cost is flowing through or how
| much goes to impact margin.
| revnode wrote:
| You're making a pretty fundamental mistake. I am not
| speculating about the elasticity of rent. If taxes went
| to 0, would rent go down? Probably not.
|
| So what?
|
| The percentage of rent that is taxes is exactly the
| amount paid in taxes by the landlord. Period. It is an
| absolute number.
| jonahbenton wrote:
| No. Property tax rates are extremely- some would say
| criminally- low in NYC. I would think it unusual for more
| than 20% of rent to go to property tax.
|
| Mortgage much much more likely to be the dominant expense
| for a residential landlord, but varies significantly with
| age.
|
| There are many longtime landlords for whom their tenants
| are now nearly all profit. Which is INSANE.
| revnode wrote:
| Why are you assuming he lives in NYC?
| jonathankoren wrote:
| The renter is not paying the property taxes. The landlord
| is. This feels like a slight of hand that leads to double
| counting.
| azinman2 wrote:
| And what do you think rent price includes?
| revnode wrote:
| That's not how things work. When you file your taxes,
| your rental properties will be treated as a business and
| the taxes paid there are a business expense. They are
| deducted from any rental income before the income is
| counted for the landlord. It is essentially as if the
| renter is paying the government directly.
| abfan1127 wrote:
| I'm entirely sure that landlord is not taking a loss on
| those property taxes. It is passed onto the renter.
| sixothree wrote:
| And don't forget your healthcare costs.
| sdenton4 wrote:
| "To some economists, the question is moot: Americans
| already pay a massive "tax" to fund health care, they
| say. It just happens to go to private insurance
| companies, rather than the federal government."
|
| ...
|
| "Health insurance costs raise the average effective tax
| rate on American labor from 29 percent to 37 percent,
| they said."
|
| https://www.washingtonpost.com/business/2019/10/16/americ
| ans...
| ch4s3 wrote:
| > Last year I paid 17% of my total income in taxes.
|
| Was that in NYS? It doesn't take a lot of income to hit the
| state rate of 6.33%, everything after $80,651 filing alone,
| which isn't unusual downstate. You can add roughly 3.8% to
| that if you live in NYC and another 22% Federally, all just
| on income.
| jrodthree24 wrote:
| Probably depends what you mean by high income. I think
| someone making 100k will not pay that much and that is
| considered high in a lot of places. But I am not sure that is
| considered high in NYC. High is probably more like 150k -
| 200k+ and that still wont be anywhere near 60%.
|
| I do get to ~40% when you add up federal, state and city. I
| don't think anyone is really looking at an actual 60%. Maybe
| 50% if you're making like over a million.
| colatkinson wrote:
| Median household income in NYC for 2020 was $67k [0]. $100k
| (especially for a single earner, as is often the case in
| tech) is considered quite high, but not outrageously so if
| that makes sense? That's "1BR apartment in a nice but not
| too trendy neighborhood outside of Manhattan" money, so
| well on the upper side of middle class. I think people tend
| to overestimate how much money those outside of the tech
| bubble actually make.
|
| [0] https://www.census.gov/quickfacts/fact/table/newyorkcit
| ynewy...
| charrondev wrote:
| I'm in Quebec so I paid 29% on everything over 66k to
| federal and my provincial rates were 20% (over 50k), 26%
| (over 100k), and 29% (over 150k).
|
| We also have a 15% sales tax. I paid more than a 50%
| effective rate last year. This is the cost of our social
| safety net. It feels like too much too me and I'll be
| relocating next year.
| bawolff wrote:
| Quebec has one of the higher tax rates in canada. You
| still get a similar safety net in the rest of canada for
| lower (albeit still high if you are a high earner) taxes.
| HEmanZ wrote:
| I don't think the op is talking about you. Many professionals
| in NYC already pay over 40% in effective income tax.
| [deleted]
| hervature wrote:
| I don't want to be rude, but if you paid 17%, that's
| basically the minimum income tax rate (10+4+3) for NYC.
| That's pretty far form the OP's "NYC high earners". Of
| course, if you got credits, that's orthogonal as normally
| those credits cost more than they are worth. For instance,
| the child credit is far from the cast of raising a child.
| Spooky23 wrote:
| If you own your home and are married the rate comes down
| until you make >500.
|
| I live in NY, not NYC and pay ~18%, or ~22% with property
| tax.
| ABCLAW wrote:
| If you're a "high earner" there are a panoply of services
| that allow you to structure your income, wealth
| appreciation, or other forms of wealth generation in tax-
| optimized vehicles.
|
| The tax universes at 200k/yr and 500k/yr-2m/yr income look
| very different.
| mortehu wrote:
| If we're talking wages here, what are the options
| exactly? Is there anything bigger than 401(k)?
|
| This is ignoring charity, which I believe is available to
| anyone anyway.
| tbihl wrote:
| I am not an accountant nor someone who benefits from
| these deductions, but I'm casually interested. From what
| I've seen, a few: 1. Charity can be meaningfully
| different from chipping in $200 to something if you can
| afford to pay for large parts of a program, meaning
| things can have your name on them, or you can get events
| that you care about hosted at your church while saving on
| your taxes. 2. Tax advantaged accounts everywhere. Max
| out all retirement of course, but also education accounts
| for your four kids. Then I think there's some interesting
| tax advantages to whole life insurance, but I don't know
| which end those come on. 3. Structuring more of your life
| as a business. For example, I use my affordable car
| almost exclusively for work but it's not worth the
| trouble to track it for deductions because I still do
| best with standard deduction. Once you pass that, may as
| well track everything. And you should buy a large SUV
| instead of a minivan for your family so you can use the
| more favorable depreciation schedule that encourages SUV
| use over minivan and car use. Deduct your laptop and
| phone and phone plan because if you're making a lot of
| money, there's almost no chance you're using those for
| personal stuff more than for business. Probably some
| travel and dining fit as deductions too. Clothing, maybe?
| This is all completely legitimate (well, maybe it's not
| because of my ignorance on particular applications, but
| the spirit is consistent with how deductions work.)
|
| You also may have the ability to structure some of your
| income as business appreciation so as to not pay taxes
| yet. True, it's still trapped until you pay taxes, but
| it's still resources you have available to you that
| haven't yet caused you to suffer tax expenditures. As a
| rule, you should never volunteer taxes that you can
| legally defer.
|
| It'll all add up, though probably not to an overwhelming
| amount. My impression is that a lot of the exaggerations
| of low tax rates come from very slimy accounting driven
| by agendas (to say nothing of expressing taxes in a given
| year as a fraction of total accumulated wealth.)
| MrWiffles wrote:
| I believe - someone more financially literate (and far
| richer!) correct me if I'm wrong - that you can convert
| some of those wages into various different vehicles and
| get paid in non-wage forms in certain cases. Correlation
| != causation of course, but if you're making $500k/year
| chances are pretty good a large chunk of that is _non-
| wage income_ such as capital gains, corporate bonuses,
| trust funds, etc. And even if it was all wage-derived,
| over time you could easily realize major capital gains on
| it if you 're lucky enough to (a) make a huge chunk 'o
| change, (b) have low-enough cost of living to be able to
| move it into investments and then (c) have enough life
| stability to be able to continue this pattern for several
| years or decades (or better yet, have grandparents and
| parents who did then passed the wealth down to you). Even
| after taxes as high as 50%, with enough raw wage income
| you can definitely pivot your "margin" into vehicles that
| yield serious ROI over time, and can even leverage the
| highly disparate cost of living to your advantage: use
| NYC's housing market to justify a ridiculous salary, then
| live super cheap out there somehow (insert hand-waving
| magic reference here), and use the difference to buy
| housing out in, say, rural Texas or Kansas before the
| pandemic, rent it out via property company, reap profit
| month-after-month.
|
| From there you follow the directions on your shampoo
| bottle:
|
| 1. Lather
|
| 2. Rinse
|
| 3. Repeat
| bingohbangoh wrote:
| I paid 38% of my total income in taxes in New York City.
| oneoff786 wrote:
| Isn't this sort of guaranteed to fail? High earners already
| have great insurance from employers. There's not likely to be a
| mechanism to get those benefits back as dollars like you would
| expect in a national scale steady state system.
| buescher wrote:
| Somehow they have private insurance in Europe too. Germany
| has universal health care and you are well advised to get
| private insurance if you make enough that the state will
| allow you to buy it. The threshold is a salary of about
| $68K/year in US dollars.
| kmonsen wrote:
| The VOX in the weeds healthcare people looked at it some time
| ago, and most healthcare economists thinks it is not possible
| for states to do something here.
| outside1234 wrote:
| Remember that this expense is also reducing the cost of
| employers.
|
| One of the best ways to finance this would be a payroll tax
| that is basically equal (in aggregate) to the insurance the
| company is (usually) already paying.
| lotsofpulp wrote:
| Big employers like having health insurance tied to
| employment. It makes changing jobs a riskier maneuver for
| employees as they do not know the quality of the other jobs'
| insurance coverage, and it creates higher overhead costs for
| smaller employers so it provides a competitive advantage
| there too.
| nerdponx wrote:
| > they do not know the quality of the other jobs' insurance
| coverage
|
| And the fact that you can't actually take time off of work
| to pursue a career change or look for a new job, because
| you need your job in order to be able to afford basic
| healthcare. Which makes it a lot harder to pursue a career
| change or look for a new job, because you are stuck/busy at
| your current one + whatever other life responsibilities you
| have (not to mention the really high commute times in NYC).
| maxerickson wrote:
| I mean, they can lobby against it, but other than that,
| what does it matter that they don't like it? It's not like
| they are so management heavy that they can swing a vote.
| mupuff1234 wrote:
| They won't have much of an option. I don't see them closing
| up shop and leaving NY if the talent is there.
| ipaddr wrote:
| I do, the talent exists elsewhere cheaper
| countvonbalzac wrote:
| No it doesn't. If it did, they would already hire those
| people and get rid of their more expensive talent.
| browningstreet wrote:
| Pretty specious argument in the days where SF companies
| are mandating RTO when it could be far cheaper to
| negotiate to WFH status those employees who didn't want
| to be in the bay area or bay area offices anymore.
| com2kid wrote:
| It isn't just talent, it is local ecosystem.
|
| Large metro areas have a large # of services available.
| From office furniture delivered in hours to a wide range
| of service industries available on demand.
|
| From food delivery to sign printing to courier services,
| large, dense, cities have economics of scale.
| adolph wrote:
| > a payroll tax that is basically equal (in aggregate) to the
| insurance
|
| Whereupon there is no reduction in cost to any employer.
|
| Theoretically there could be a reduction because the state
| would be a larger pool of cross-subsidization than any
| particular employer. In reality the costs are worse since the
| state will use the taxes to subsidize non-employed persons.
| endisneigh wrote:
| If you think employers will share the savings with their
| employees, think again.
| drm237 wrote:
| I don't think they're saying that at all. I think the point
| was, a payroll tax won't necessarily increase costs for a
| company because it would be offset by eliminating the
| current healthcare costs.
| endisneigh wrote:
| Right, but my point is that to keep the relative
| advantage they'd have to pay.
|
| For example imagine a company attracts talent by paying
| median + healthcare, and another that just paid median.
| For the latter they would have more costs, no?
|
| The savings aren't offset unless they were already
| offering the incentive.
| [deleted]
| jjoonathan wrote:
| Yes! The private-insurance-mimicing payroll tax is by far the
| best path.
|
| Nobody is going to believe that there are savings to be had,
| so it's best to start by reducing friction.
| sli wrote:
| Only because people are conditioned to only seek medical
| attention when it's absolutely necessary, because it's too
| expensive to be proactive even with insurance.
| lr4444lr wrote:
| There is nothing stopping NY employers now from just giving
| people enough cash to buy a plan on the ACA marketplace.
| You're assuming this upcoming plan will have offerings
| employees will want, and charges employers whether or not
| this is the case.
| kmonsen wrote:
| This came up in the VOX in the weeds on healthcare policy some
| time ago. Their conclusion from the people that had looked into
| it is that it is sort of impossible for states to do this.
| Can't really remember the reasons.
|
| There was another state that was trying something like this, I
| believe it was Vermont.
| 7speter wrote:
| I'm guessing the economy of scale for such a buy in isn't
| enough, and that states would have to take out as much debt
| as their yearly budgets or even more. Even a Elizabeth
| Warren's proposed solution was something like 17x the federal
| budget.
| astura wrote:
| Where does 60% come from?
|
| I used this calculator - https://smartasset.com/taxes/income-
| taxes
|
| It said if I (married) made $675,745/year in Manhattan I'd pay
| 39.59% of my income in taxes.
| Vladimof wrote:
| 4 states would be about 1/3 of all of USA's population too...
| johnsanders wrote:
| One of America's best ideas. Laboratories of democracy. Maybe
| it works.. maybe not. But the rest of us learn from whatever
| happens.
| gnopgnip wrote:
| NY currently greatly restricts how health insurers can
| discriminate on price based on age to the point that age
| basically isn't a factor. But most states allow for a ~3x
| price difference based on age. The other state with a similar
| rule, Vermont, has a form of single payer insurance as well
| chmod600 wrote:
| One thing I don't understand is how you can make healthcare
| "equal" in the sense that it will stand up to court challenges in
| the U.S.
|
| Free speech is a self-service right, so the government can just
| step out of the way and everything is fine. But healthcare
| requires the government to do a lot. _Not_ doing something
| equally (like stepping out of the way of free speech) is easier
| than _doing_ something (like healthcare) equally.
| kevin_thibedeau wrote:
| The SC is trying its best to devolve all powers to the states.
| They can't have it one way for a contentious issue and then be
| hypocrites for anything else.
| ceejayoz wrote:
| Who's gonna stop them?
| et2o wrote:
| I'm an MD who trained in NYC. I have also had emergency surgery
| in the NHS at one of their most prestigious hospitals in London
| and so I feel like I've seen the system a little bit from the
| inside.
|
| It was far cheaper for me than it would have been as a Brit in
| the USA, but the standard of care was lower. They didn't have
| some technical and staffing resources late in the afternoon that
| would be a baseline in any of the hospitals I've been at in the
| USA. The English doctors were just kind of apologetic and bashful
| about it, talking to someone they knew was an American doctor who
| knew what kind of specific diagnostic algorithm was appropriate.
|
| The NYC hospitals are somewhat financially strained as it is.
| Especially the public hospitals (Bellevue, Elmhurst,
| Metropolitan).
|
| Also related would be care at the VA hospitals, which is
| slower/worse than care at NYC flagship hospitals. But as a
| society we don't want to prioritize or pay for good care for
| veterans, so it is what it is.
|
| I predict this will continue to basically just produce a more
| two-tiered system in the US. Most doctors who have a choice
| (large group practices) will take the wealthy patients with
| private insurance, and the big hospitals and whomever else who
| don't have a choice will be forced to accept the NY single payers
| (basically the existing model, where the poor and 65+ are already
| covered under Medicaid and Medicare already). It will likely
| strain these systems even further, as reimbursements from
| Medicaid/Medicaid are insufficient to run large health systems
| which depend on higher rates from private insurers (payor mix).
| Good luck there.
|
| In NYC even more physicians and group practices will try to go to
| alternate models such as cash-only. Try being on Medicaid or
| Medicare and finding an outpatient psychiatrist in NYC now as it
| is. This will extend to more PCPs, chronic disease specialists,
| etc.
|
| Some patients will get better and more affordable care, but some
| will also get much worse care. It will be interesting to see what
| happens. I'm not necessarily opposed, but this is absolutely not
| going to be a clear and decisive win on all fronts as some
| commenters are suggesting. The US healthcare system, if you have
| private insurance, is the best in the world already in terms of
| level of service and access to rapid specialty and high-end care.
| docstryder wrote:
| If we go by data, the US healthcare system is the most
| expensive (not arguable) and is not even in the top 5 among
| developed countries in the most important measures. Also a doc,
| though that is not really relevant for this discussion.
|
| one of these references is from an US insurance company who you
| would think would be biased for US healthcare
|
| https://www.cignaglobal.com/blog/healthcare/top-10-countries...
|
| https://www.washingtonpost.com/world/2021/08/05/global-healt...
|
| https://www.internationalinsurance.com/health/systems/
| et2o wrote:
| I said "if you have private insurance," which I think is the
| key qualifier. One of the other commenters expanded upon it
| well below.
|
| I'm not making an argument for cost-effectiveness either.
|
| We can get private insurance to pay for elective surgeries,
| new medications, etc. that are either not covered in other
| countries or have extremely long wait periods. And the higher
| reimbursement I think is helpful for providing staffing and
| paying for equipment that they (in my admittedly n of 1
| experience) simply didn't have for me. I suppose it is a
| tradeoff.
| erosenbe0 wrote:
| This is a good take. Single payer might work in the USA using
| HMO plans funded by taxes, income/asset linked tiers of
| coinsurance, tax increases, major efficiency corrections,
| reduced barriers to entry, and mix of deregulation and
| regulation to increase competition.
|
| Also, the US healthcare system is the excellent and one of the
| world's best if :
|
| A) you have good insurance or medicaid/medicare in the right
| place.
|
| B) you have transport to potentially drive some distance to
| deal with occasional wait times or to find in-network providers
|
| C) you can navigate the sometimes byzantine billing nightmares
| that can occur where your coverage is denied on medically
| necessary or contractually covered care; or your enrollment in
| a subsidized program is denied, late; or you are indigent,
| incapacitated or elderly need an advocate to assure you get
| enrolled in correct coverage.
| et2o wrote:
| Great points. Yes those are the major barriers. If you have
| all those, things can go well. Obviously heaps of people in
| the USA do not.
| chmod600 wrote:
| I'm skeptical, but I'd like to see it pass. Such a debate in this
| country and it would act as an experiment. It would probably take
| a while for the consequences (good and bad, as I don't believe it
| would be purely one or the other) to become apparent.
| colechristensen wrote:
| One of the arguments for the federal system is that states _do_
| get to experiment and the ones that work go national.
| gbronner wrote:
| The problem here is that you are going to get regulatory capture
| by the healthcare unions. So we'll get worse service at higher
| cost, not to mention incredible fraud
| jmyeet wrote:
| Cue the Republican challenge arguing the state has exceeded its
| authority and this is a Federal issue (just like how Ajit Pai
| removed net neutrality saying it wasn't a Federal issue but then
| turned around and challenged California's net neutrality as being
| within the FCC's authority).
|
| As for the NY bill, I'll be interested to see what this looks
| like. There are many variations on single-payer. For example, the
| NHS in the UK has many medical professionals (including primary
| care physicians) as government employees. In Australia, Medicare
| works by government rebate.
|
| The other aspect will be how this will impact coverage out-of-
| state, employment coverage and employment insurance premiums.
|
| You see many reactionaries argue "but it will raise taxes!".
| Welll... yes and no. You're already paying for your employer
| health insurance. This just shifts that cost to the government
| (sort of) but now health insurance isn't tied to employment.
| Alexbades wrote:
| I will kidnapp you soon hacked
| ParksNet wrote:
| 50% of health resources are used in the final 5 years of life.
|
| The young should not pay for the healthcare of the elderly.
| Society should be apportioned into different age categories, and
| funded separately, with a 'base' tier for all citizens and legal
| residents, and a higher tier for those with private or employer
| insurance.
| tsol wrote:
| So what do we do with the sick and poor elderly folks? It
| provides a benefit for the younger as well in that junior
| doesn't have to worry about grandma dying of an untreated
| illness
| Sohcahtoa82 wrote:
| > The young should not pay for the healthcare of the elderly.
|
| I take an alternative view. When you're young, the payments you
| make into Medicare taxes are to take care of you later when you
| need it. A long-term HSA of sorts.
| simulate-me wrote:
| Who funds the more expensive tiers?
| thallium205 wrote:
| I mean the young get kicked out of their commercial plans at
| age 65. So in a way they don't pay for it at the commercial
| level.
| Krasnol wrote:
| > The young should not pay for the healthcare of the elderly.
|
| Why?
| notch656a wrote:
| I think funding the elderly is a lofty goal, but I don't see
| a good intellectual argument for FORCING our children to pay
| for our healthcare. You shouldn't view your child (nor your
| neighbor's child) as your own personal piggy-bank to extract
| from when you get ill.
|
| IMO our goal should be to hand down resources from parent to
| child, not the opposite direction.
|
| If I made this story a bit more personal and wrote ("I am too
| ill to work anymore, so I drove to my son's house and took
| $200 off his counter to buy my medication) HN would be
| reacting with outrage.
| notreallyserio wrote:
| What alternative do you propose? Suicide booths?
| notch656a wrote:
| Literally any other option than telling our children they
| must involuntarily pay, like they're our own personal
| piggy bank. Saving, asking nicely, charity, debt/mortgage
| the house, and other forms of voluntary transactions
| sound acceptable. If you truly have no other options then
| you can make the moral judgement whether you want to
| involuntarily take from our children because you think
| the investment on yourself is worth more than the
| investment on the youth.
| Krasnol wrote:
| I don't understand your argument.
|
| You are helping others & others help you. What's the
| problem?
|
| > If I made this story a bit more personal and wrote ("I am
| too ill to work anymore, so I drove to my son's house and
| took $200 off his counter to buy my medication) HN would be
| reacting with outrage.
|
| How about making the story more fitting the reality here:
| You drive to your sons house and ask him to help you with
| your health bill and he helps you because...why wouldn't
| he?
| notch656a wrote:
| >You drive to your sons house and ask him to help you
| with your health bill and he helps you because...why
| wouldn't he?
|
| Asking is fine. Telling them they must is not. If the
| mechanism for payment from the youth to the elderly is
| voluntary I have no problem with it.
| Krasnol wrote:
| It kinda is voluntary. If you don't like it, you can
| leave the country which wants you to pay.
|
| I don't get why you have a problem with that. It sounds
| to me like some anti-social behaviour pattern. Don't you
| pay for taxes or Government services too? This is how a
| civilized society works. The attitude you display here
| has become a bad joke when people talk about the US
| health system. You must be aware of that.
|
| What do you expect people to do which can't afford to pay
| their health bills because they've been unlucky or
| something like that? Are they supposed to just die?
| nybble41 wrote:
| > It kinda is voluntary. If you don't like it, you can
| leave the country which wants you to pay.
|
| Voluntary would be _staying where you are_ and still not
| being forced to pay. When a mugger presents their victim
| with a choice like "your money or your life" they're not
| paying _voluntarily_ just because there was another
| option. You don 't have the right to evict people from
| their homes any more than you have the right to take
| their money.
|
| > It sounds to me like some anti-social behaviour
| pattern.
|
| The attempt to normalize theft is the only "anti-social
| behaviour pattern" here.
| airstrike wrote:
| > The young should not pay for the healthcare of the elderly.
|
| The same way responsible drivers should not pay for reckless
| ones? Or responsible homeowners shouldn't pay for reckless
| ones?
|
| The whole idea of insurance is to distribute the costs so that
| no one has to bear long tail costs alone...
| ceeplusplus wrote:
| Long tail costs are things like freak car accidents, hail,
| etc. Reckless drivers should and are charged more because
| their costs are higher as a result of their own choices.
| Obese smokers should be charged more than healthy people but
| they're not because ACA says you can't discriminate based on
| pre-existing conditions. That means healthy people end up
| subsidizing lung cancer treatment, heart disease treatment,
| insulin, etc. for fat people.
|
| edit: correction, ACA permits charging tobacco users extra.
| But not, for example, weed users.
| airstrike wrote:
| Older people _do_ pay more for healthcare insurance...
| nybble41 wrote:
| Yes, because age (like smoking) is one of the few factors
| ACA Marketplace plans can take into consideration. But
| _healthy_ older people pay the same premiums as
| _unhealthy_ older people, which means one of these two
| groups is being overcharged. Moreover, it means that
| there is less incentive (not none, but less) to make an
| effort to end up in the first group as it won 't affect
| your health insurance costs.
| rabuse wrote:
| I absolutely agree with charging people with poor lifestyle
| choices more for their healthcare. They cost more, so they
| should pay more.
| nybble41 wrote:
| > The same way responsible drivers should not pay for
| reckless ones? Or responsible homeowners shouldn't pay for
| reckless ones?
|
| Yes, exactly. Reckless drivers and reckless homeowners should
| pay higher premiums, as their insurance covers a higher risk
| ( _a priori_ expected cost) compared to responsible drivers
| and responsible homeowners.
|
| > The whole idea of insurance is to distribute the costs so
| that no one has to bear long tail costs alone...
|
| The "whole idea of insurance" from the buyer's perspective is
| to pay a fixed premium instead of carrying risk. The value of
| the service, and thus the premium one is willing to pay, is
| determined by the risk being mitigated for each individual
| customer. The existence of "risk pools" is important for the
| insurance provider's cash flow, but a mere implementation
| detail to the customer. Insurance is not a subsidy or
| charity; if you and others like yourself are expected to cost
| more on average than some other group, you should expect to
| pay more. In a competitive insurance market those with higher
| risks will pay higher premiums; a company that attempted to
| charge everyone a flat rate would find itself either bankrupt
| or incapable of competing on premiums for any but the most
| expensive (highest-risk) customers.
| puffoflogic wrote:
| Private auto and homeowners insurance are not price-
| insensitive, despite being mandatory (former case, by
| mandate, latter case, in practice for mortgaged property). If
| insurance companies paid out indiscriminately to the
| reckless; i.e. failed to manage their risk; then their
| premiums would get too high and they would lose their average
| customers.
|
| There is no analogue for taxpayer-funded healthcare. There is
| no practical upper bound on the cost. The over-users will not
| run out of other people's money. Unless, of course, there are
| death panels; everyone loves death panels.
| caboteria wrote:
| Anyone who hopes to someday be elderly should pay for the
| healthcare of the elderly.
| liminal wrote:
| "Private insurance that duplicates benefits offered under New
| York Health could not be offered to New York residents. (Existing
| retiree coverage could be phased out and replaced with New York
| Health.)"
|
| That is an important paragraph. If you want good public health
| care, you need to make sure the rich use it too. Canada does it
| by not allowing doctors to work in both the public and private
| systems. This law takes a different approach, instead barring the
| insurance companies from competing. Wonder if it will hold up in
| court.
|
| Without this paragraph I don't think it could be a good system.
| With it, there's at least some hope.
| exabrial wrote:
| I really want the government deciding what it considers
| "covered". Didn't get your Vaccine? Too bad, Democrats voted they
| won't cover your health care costs of a hospital visit.
| Unprotected Sex? Too bad, Republicans decided they won't cover
| your Plan B the next day. Your health choices are your business.
| Both sides have an agenda they will leverage and hold you hostage
| with.
|
| Leave the government out of healthcare. They can't get make a
| functional driver license system, or a post office that doesn't
| dump billions of tons of C02 into the atmosphere delivering spam
| while being open between 11a-4pm, or run an airline security
| service like the TSA that actually stops threats and doesn't take
| away your Grandma's nail trimmers.
| nanliu wrote:
| The private sector also established they will value profit
| above all else like pre-existing conditions they won't cover,
| what's in vs. out of network, who I need approval before I go
| see a specialist, limits on overall coverage, an ambulance ride
| that costs more than a first class plane ticket.
|
| I want a system that measures outcomes that doesn't sap double
| digit GDP, but the incentives are not structured in a way for
| success in this country (private or public).
| goatcode wrote:
| Coming from a country that has this, there should be caution: it
| gets more affordable, but you get what you pay for. In my country
| of origin, you get a partially-paid-for ride to the emergency
| room, where you pay for things like casts, non-ward rooms, dental
| care out of pocket. There is no prescription coverage. There is
| no optometry coverage. I would wait significant chunks of a year
| for procedures and diagnostics. To cover the things that aren't
| covered, most have private insurance through work or also out of
| pocket.
|
| Since moving to the US, it is more expensive (than next to
| nothing), but I actually get good care. Several conditions that
| were ignored or misdiagnosed for me are now cured. My life might
| be significantly shorter had I not come here.
|
| If NY does this, the near zero chance of my moving there ever
| would go to absolute 0. It is a terrible system for any place
| that does not have infinitesimal state or national government
| expenses and more-than-60% kind of taxes (e.g., Scandinavian
| countries).
| droopyEyelids wrote:
| Two points:
|
| 1) In the USA, one must be pretty well situated to get the
| quality of healthcare you describe. MANY people go without
| prescriptions, and get inadequate care already.
|
| 2) If you add up what we pay in health insurance premiums plus
| employer contributions, especially if you have a family, we're
| generally in the same league of paycheck-subtraction as a
| European country with universal healthcare.
|
| So while I agree with your overall point that it could end up
| worse than where we started, I don't think thats a guaranteed
| outcome.
| version_five wrote:
| Would healthcare overall in e.g New York be equivalent though?
| In Canada, we have "free" healthcare but literally have no
| other option so it's the Soviet style mess you'd expect a
| government monopoly to be. But would this bar paid healthcare?
| Couldn't people still have health insurance and get private
| care? Is there something preventing that?
| kmonsen wrote:
| I don't know why the medicare for all plans need to ban
| private healthcare. Norway and UK has free healthcare for
| all, but still private options available for people that want
| to pay extra. That is also reducing the load on the public
| system so I can't really see why it is negative.
| KoftaBob wrote:
| This bill doesn't ban private insurance, it does however have
| this rule:
|
| "Private insurance that duplicates benefits offered under New
| York Health could not be offered to New York residents."
|
| So in other words, private insurances can only be offered if
| they provide benefits that surpass whatever the public option
| has.
|
| I imagine that private insurances will logically offer more
| benefits regardless, otherwise why would someone pay extra to
| use them over the public option?
| codefreeordie wrote:
| that will mean, though, that it will be impossible to get
| insurance to actually cover the things that the public
| system "covers" if you wait 35,600 years for your turn
| monocasa wrote:
| Why? Wouldn't a line skip be by definition something that
| the public system isn't offering?
| codefreeordie wrote:
| I haven't read the full text of the bill, but presumably
| not. The intent will be to disallow private coverage for
| any service that the government would provide,
| specifically because they would want to make sure that
| people with money couldn't avoid the public system.
|
| That's how it ends up working in many places with
| government care
| monocasa wrote:
| I don't know of any healthcare system where what you're
| describing is the case outside of outliers like North
| Korea. Even in the UK with NHS, there's a whole system of
| private insurance and private hospitals too.
| kmonsen wrote:
| In Norway and UK there is public healthcare, but you can
| pay to skip the lines if you want to. I don't know why we
| would go full socialist in the US when living in a
| capitalist society. Should we only get cars allocated to
| us or something as well?
|
| I am not hugely in favor or capitalism, but I can't see
| anything better or a way to replace it even though I am a
| social democrat. Let people with money spend them as long
| as we provide a decent floor for everyone.
| version_five wrote:
| I went to a clinic in Canada a few years ago to see a
| doctor. My provincial health card had expired and I
| didn't know. I was sick and wanted a consultation with
| the doctor. I said I would pay cash and was told that
| they are not allowed to charge people who are eligible
| for public healthcare. So I had to go and wait at our
| equivalent of the DMV (while sick and seeking medical
| attention) to get my health card renewed before I could
| see a doctor. I'm sure there are countless bureaucratic
| nightmare stories coming out of the US health insurance
| system, there will be countless more under a public
| system
| criddell wrote:
| I'm a Canadian living and working in the US and I'd take the
| Canadian system any day of the week.
|
| I think it's crazy that your access to healthcare is
| dependent on your employment.
| oh_sigh wrote:
| Are you making that decision because the quality of care
| you've received is better in the Canadian system than the
| American system, or because you disagree with how the
| American system is structured?
| rtlfe wrote:
| > Are you making that decision because the quality of
| care you've received is better in the Canadian system
| than the American system
|
| That would depend completely on their job in the US. If
| they're a line cook, care was better in Canada. If
| they're a software engineer, it's better in the US.
| version_five wrote:
| But it's also crazy that your access to healthcare is based
| on how the government prioritizes your need of it.
|
| I agree with the idea of public healthcare, but not as a
| legislated monopoly. And that's true for government
| services generally. Monopolies don't benefit anyone except
| the monopolist, and competition makes everyone stronger. If
| the government wants to use it's buying and borrowing power
| (and maybe even taxation to the extent voters tolerate it)
| to provide a universal healthcare option, that's a big win.
| But if they want to push out other market participants in
| the name of some kind of fairness - well instead of having
| two-tier healthcare, everyone is on the bottom tier
| bdzr wrote:
| > But it's also crazy that your access to healthcare is
| based on how the government prioritizes your need of it.
|
| So does every private insurer under the sun. You've never
| had insurance deny access to care? No insurer can afford
| to give an MRI to everyone a doctor wants.
| throw0101a wrote:
| > _But it 's also crazy that your access to healthcare is
| based on how the government prioritizes your need of it._
|
| Doctor's prioritize need. More sicker, more quicker
| 'service' / treatment.
|
| > _I agree with the idea of public healthcare, but not as
| a legislated monopoly._
|
| There is no monopoly on health care in Canada: if you
| want to cut a cheque you can get private care. What is
| legislated is that if you take provincial funding you
| _cannot also_ take private funds. It 's either-or.
| yazaddaruvala wrote:
| At least in Vancouver there are private clinics[0] where
| you can get MRIs, CT scans, endoscopies, etc within the
| week if you are willing to pay.
|
| [0] e.g. https://www.timelymedical.ca/
| wvenable wrote:
| > But it's also crazy that your access to healthcare is
| based on how the government prioritizes your need of it.
|
| Triage is a pretty universal concept.
|
| Healthcare has difficulty with competitive market effects
| because the amount anyone will pay to live is essentially
| infinite.
| speed_spread wrote:
| You're not supposed to be able to get private healthcare in
| Canada, but actually there are plenty of fancy clinics that
| will fix you up on the spot if you have money. It's all hush-
| hush because those in power are the primary users of that
| parallel system. It's not a criminal underground but an
| unregulated mezzanine, yes?
|
| Also, in my experience, public healthcare _can_ be quite
| good, but the quality of service varies a lot across regions
| and institutions.
| version_five wrote:
| > It's all hush-hush because those in power are the primary
| users of that parallel system
|
| Any hint you can provide of how to look into this? I know
| there are private clinics for certain things, but I would
| be very interested to see what options there are for my
| family
| throw0101a wrote:
| > _You 're not supposed to be able to get private
| healthcare in Canada_ [...]
|
| Sure you are. There is no government monopoly on health
| care in Canada: if you want to cut a cheque you can get
| private care. Nothing illegal about it.
|
| All (family) doctors in Canada are private businesses. It's
| just that most of them hook into the provincial payment
| system. Similarly for hospitals: they are _not_ government
| _run_ , just funded through government. If you wish to set
| up a private clinic and/or hospital and not take government
| funding, there is no legal impediment to do so.
|
| What is legislated is that if you take provincial funding
| you _cannot also_ take private funds. It 's either-or.
|
| > _It 's all hush-hush because those in power are the
| primary users of that parallel system._
|
| It's not hush-hush, it's just most of us plebes cannot
| afford fancy pants clinics.
| A4ET8a8uTh0 wrote:
| That was the part that pissed me off in Poland. Long story
| short, country moved to a very weird spot healthcare-wise,
| where, in theory, 'money would follow the patient'. Doctors
| did well ( cuz they tend to be smart and are well organized
| ); patients.. not really. I was young and very, very naive
| at the time. I figured that if the guys, who are voting for
| this have to use it, it won't be so bad.
|
| I did not anticipate that they would grant themselves
| special kind of access to healthcare. Like I said, very,
| very naive.
| mtalantikite wrote:
| > If NY does this, the near zero chance of my moving there ever
| would go to absolute 0.
|
| Are they proposing kicking you off your insurance? From the
| bill:
|
| > SUMMARY OF SPECIFIC PROVISIONS:
|
| Every New York resident will be eligible to enroll, regardless
| of age, income, wealth, employment, or other status. There
| would be no network restrictions, deductibles, or co-pays.
| Coverage would be publicly funded. The benefits will include
| comprehensive outpatient and inpatient medical care, long-term
| care, primary and preventive care, prescription drugs,
| laboratory tests, rehabilitative, dental, vision, hearing, etc.
| all benefits required by current state insurance law or
| provided by the state public employee package, Family Health
| Plus, Child Health Plus, Medicare, or Medicaid, and others
| added by the plan.
|
| As someone that has lived in NYC for 15 years, I'd really love
| to see this happen.
|
| Edit:
|
| > Private insurance that duplicates benefits offered under New
| York Health could not be offered to New York residents.
|
| So yes, I guess it would be kicking those off of their current
| private insurance. It sounds like it'd force private insurers
| to offer plans that would augment off of a base of public care.
|
| I'm still fine with this.
| [deleted]
| [deleted]
| bdzr wrote:
| Network restrictions are dumb, but copays and deductibles
| serve a purpose. Healthcare isn't unlimited, and free
| services leads to long wait times because people don't reduce
| demand (e.g. going to the doctor for a stubbed toe). Certain
| specialities already have enormous wait times. You're in NY,
| try seeing a neurologist for a non-emergency. Given that an
| enormous amount of first appointments are "come back in a
| month if this is still bothering you" - copays need to exist.
| Patients have to have "skin in the game" as Andrew Yang would
| say.
| ceeplusplus wrote:
| I read through the bill and there are no specifics written on
| how the entire thing is supposed to be funded, other than
| saying that payroll taxes will be increased to fund it. My
| guess is that once the numbers come out on how much tax would
| have to be paid that this bill would be dead.
| yazaddaruvala wrote:
| Companies currently provide health insurance and pay per
| employee.
|
| Per employee costs go up due to health care payroll taxes.
|
| Per employee costs come down due to not paying for health
| insurance.
|
| Overall, net-neutral cost to companies and simplifies
| health care payments for hospitals, clinics, etc so fewer
| employees to explain and collect payments so cost of care
| comes down. Seems like a win - win - win.
| RHSeeger wrote:
| If you follow this specific thread, the discussion looks
| like this
|
| >>>> Person complaining about how his previous state-run
| health care system was awful
|
| >>> Person replying that your current plan will still be
| there, no one will force you to take the state run plan
|
| >> Person commenting on how funding for the bill will
| kill it
|
| > Response that funding will come from the money that
| companies were paying on health plans.
|
| So if everything in this one thread is true, then
|
| - Companies will continue to offer the health plan they
| currently offer
|
| - The state will provide a single payer health plan
|
| - The money that companies currently pay on health plans
| will pay for both of those, with no increase in cost to
| the employee
|
| Clearly that's not realistic.
| ceeplusplus wrote:
| Health insurance is a constant cost per employee,
| effectively decreasing in percentage of income as income
| goes up. Payroll taxes scale up as your income goes up.
| So no, it's not net-neutral as it's highly
| redistributive. If single payer were implemented as a
| flat tax, then it would be net-neutral.
| Beltiras wrote:
| I live in Iceland. ETR is about 40% for me but I'm in a high
| tax bracket. None of the Scandinavian countries even have 60%
| marginal tax rate.
|
| EDIT: My MTR is ~42% so my ETR can't be 40%. I don't have a
| payslip to calculate and searching the interwebs isn't helping
| a lot right now.
| kmonsen wrote:
| Same in Norway, max marginal rate caps out at almost 50%:
| https://www.skatteetaten.no/en/rates/maximum-effective-
| margi...
| erosenbe0 wrote:
| In a high-tax US state like California the top marginal
| income tax is about 47%. This covers no health care unless
| you are over 65, disabled, or are below the medicaid
| threshold, which is low.
|
| There is also a lower rate om capital gains such as stock
| or real estate, sales (like a VAT), gas tax, vehicle tax,
| utility tax, phone tax, cable internet tax, etc.
|
| Plus, of course, employers are paying some extra payroll
| taxes per employee.
| jeppesen-io wrote:
| > Coming from a country that has this, there should be caution
|
| It's big world - without knowing which country, this is of
| little help. I'd like to see a comparison of people forced into
| debt, bankruptcy or death due to the respective medical systems
|
| This hits home because I have a friend that got cancer with
| "good" U.S. insurance and if he did not fight the insurance
| company he'd be in debt for 1mm+
| chrisseaton wrote:
| I'm from the UK, which is basically fully free-at-point-of-
| use healthcare (you pay a nominal fee for prescriptions,
| dentistry, optician) and is often championed as a great
| option.
|
| Reality is it's pretty grim. Don't know if I'd recommend it
| to other countries to be honest.
|
| Be careful what you wish for!
| rootusrootus wrote:
| > Reality is it's pretty grim. Don't know if I'd recommend
| it to other countries to be honest.
|
| As someone who's never experienced the UK health care
| system, and only know one person who has (as a foreigner,
| so they paid out of pocket and said the experience was
| positive, but otherwise not a good data point) ... I'd like
| to hear a bit more detail about how it's pretty grim, if
| you're willing to elaborate.
| chrisseaton wrote:
| I'd love to get you to listen in to a phone call where I
| try to get an appointment with my doctor. You'd have to
| be up at 0800 on the dot, while I desperately try to get
| into the phone queue. Then you'll hear me beg with the
| world rudest receptionist for an appointment, which I
| won't get.
|
| There's no incentive for these people to be helpful or
| polite, because they get paid anyway and there's no
| market, so they aren't.
|
| My American colleagues see a doctor every year for a
| checkup to catch things like cancer before they're fatal.
| The NHS would laugh in my face if I said I wanted to see
| a doctor for a checkup, unless I literally had an arm
| falling off.
| monocasa wrote:
| You don't have a yearly physical with your GP under NHS?
|
| Also, I just spent a total of seven hours last week
| making calls just to get insurance to even process my
| prescription that they had previously approved.
| chrisseaton wrote:
| There's no way in hell an NHS GP would agree to see me
| just for a physical without some very specific major
| problem actually in evidence.
|
| If you never want to see your GP again then yeah petition
| for the UK system.
| monocasa wrote:
| What does a "check up" mean?
|
| There's no way my insurance would pay for random "I don't
| think anything's wrong but I want to look for something
| anyway" outside of yearly physicals either.
| chrisseaton wrote:
| > outside of yearly physicals
|
| Yearly physical == check up. Same thing. Going to the
| doctor once a year for a general check that you aren't
| developing any issues that you weren't aware of yet and
| to monitor your health.
|
| I don't have either. I haven't seen a doctor for about
| five years I think, under the NHS system.
|
| If I phoned my NHS GP and said 'it's been a year I'd like
| you to generally check my physical health' they'd tell me
| to fuck off.
| systemvoltage wrote:
| Switzerland has private insurance just like the US and people I
| know that live in Zurich love it.
| throw0101a wrote:
| > _Switzerland has private insurance just like the US and
| people I know that live in Zurich love it._
|
| Profits are regulated (sometimes down to zero) in CH. Profits
| are unregulated in the US.
| systemvoltage wrote:
| Only for the "soziale krankenversicherung" or basic plan.
|
| US has a massive free healthcare system called "Medicaid"
| which is similar to the basic plan for low income
| individuals and families, the scale of which is unknown to
| many:
|
| > Medicaid is the largest source of funding for medical and
| health-related services for people with low income in the
| United States, providing free health insurance to 74
| million low-income and disabled people (23% of Americans)
| as of 2017, as well as paying for half of all U.S. births
| in 2019.
|
| https://en.wikipedia.org/wiki/Medicaid
|
| In addition, each state has other provisions. For example,
| California's Medical system is used by a third of
| California's population:
|
| > Benefits include ambulatory patient services, emergency
| services, hospitalization, maternity and newborn care,
| mental health and substance use disorder treatment, dental
| (Denti-Cal), vision, and long term care and supports.
|
| https://en.wikipedia.org/wiki/Medi-Cal
| tonfa wrote:
| It's not exactly like the US tho. Basic insurance is
| mandatory for every resident, insurers can't refuse
| covererage (no preexisting conditions) and pricing of
| insurance is transparent (I don't think they can
| differentiate beyond a few variables).
|
| Afaik pricing of medical procedures is defined by government
| (probably with insurers and practitioners).
|
| It's high quality but fairly expensive (relative to GDP or
| salary vs other European countries)
| HalcyonicStorm wrote:
| I understand where you're coming from related to this. We (in
| the US) hear this critique with regards to the NHS or the
| Canadian healthcare system.
|
| The part you're missing is that there is an arms race of
| pricing between healthcare corporations (there have been
| massive mergers of hospital systems) and insurance companies in
| terms of prices. We, the patients, are caught in between the
| giants while prices are going sky high and we are at our most
| vulnerable.
|
| The hope is this will fix prices to a reasonable level so if we
| choose to go for private care, those prices will also be
| reasonable. A lot of specialists that I see ask for cash
| payments and don't accept insurance. They are also overbooked
| because a lot of healthcare providers are being driven out of
| industry from the conditions.
| manuelabeledo wrote:
| I come from a country with universal healthcare too, and my
| experience is the opposite.
|
| Yes, to this day, it doesn't cover dental or vision, which is
| BS if you ask me, and there is some co-pay for certain
| prescriptions; regardless, it is a fantastic system, and I miss
| it so much every time I need to go to the doctor here in the
| US. The main reason is uncertainty: in the US, I can _never_
| know how much something is going to be, even if it starts as a
| mere visit to a family doctor, because there are uncountable
| variables that may factor in the final cost.
|
| As a result of this, I try to avoid going to the doctor as much
| as I can, and it makes me think about all the people who really
| cannot afford healthcare, and don't qualify for Medicare
| either.
| Teknoman117 wrote:
| > I can never know how much something is going to be
|
| I think the closest thing you can get to the cost experience
| of universal healthcare in the US is one of the better HMO
| providers like Kaiser. Everything is a known cost up front.
| Ar-Curunir wrote:
| Given that you were already unlikely to move to NYC, I'm not
| sure your opinion has much weight compared to that of existing
| New Yorkers...
| sedatk wrote:
| Coming from Turkey that has this, I can 100% vouch for it.
| Prescriptions are partially covered. Private insurance and
| private hospitals is an option but that doesn't mean state
| hospitals are bad. Healthcare quality is very good in state
| hospitals. It's actually one of the only two categories in
| which Turkey's in a good standing among OECD countries.
|
| It has its own wrinkles of course. For example, doctors make
| less money and their working conditions are worse than private
| hospitals. Because of that, it's common to get asked to pay a
| "knife fee" in secret for operations. Some doctors ask for an
| expensive bottle of whiskey etc. I haven't experienced this
| myself but heard about those incidents many times.
|
| However, wait times aren't long. Appointments are organized
| electronically through E-State portal. Although wait times in
| ER can be long based on your triage, that's the case with
| United States anyway.
|
| The benefits of single payer healthcare outweigh the drawbacks
| by a wide margin. You never worry about unemployment. You don't
| have homeless people due to their mental problems as they're
| treated in mental clinics. You don't worry about "getting
| bankrupt" suddenly from an unforeseen health issue. Healthcare
| costs are low even if you're not insured. That means drugs are
| cheap even though state won't cover 100% of the cost. Even
| private insurance is cheap (~$1000 a year).
|
| Yes, taxes are high in Turkey, but healthcare system costs make
| up a very small portion of it (~5%).
| standardUser wrote:
| "you get what you pay for"
|
| No country pays more for healthcare per capita than the US. If
| we could capture some of the huge chunk that goes to private
| insurance companies (each company has its own redundant staff
| and technology systems, their own execs all getting their own
| bonuses, etc), we could provide healthcare even better than we
| already provide in the US to those who can afford it or qualify
| for public programs.
| majormajor wrote:
| The US spends more per capita than other countries on
| healthcare.
|
| But that doesn't mean the US would have to pay less per capita
| in a single-payer system.
|
| So we could keep getting what we pay for in terms of capacity,
| etc, if we want. You would expect a wealthy country to be able
| to pay a premium to get a premium.
| [deleted]
| seandoe wrote:
| Interesting, from where do you hail?
| frozenport wrote:
| >> but you get what you pay for.
|
| Americans are already paying more than most places for
| healthcare but not getting a good return.
| space_fountain wrote:
| Is this true even for individuals? I think one version of the
| problem might be that we pay too little for some peoples
| healthcare and too much for others, but do the people who pay
| the most still end up with worse results?
| marricks wrote:
| Who gets "good" care here? Senators and millionaires definitely
| do. But, most people don't get good care, many people are
| missing essential care (dental), and everyone has to wait.
| Often months.
|
| We in the US pay more per capita for worse care than most other
| developed nations (Canada/UK/Nordic countries). Name your
| country where the care is worse than the US please and let us
| know how much they pay for it per capita comparatively.
| nceqs3 wrote:
| You ever been to a Canadian hospital?
| throw0101a wrote:
| > _You ever been to a Canadian hospital?_
|
| As a Canadian: yes.
|
| And the bill was $0 at the end of my father's heart bypass
| and valve replacement surgery. My friend's sister cancer
| treatment also had a bill of $0.
|
| Finished filing my taxes last month, and my average rate
| (provincial+federal) for last year was 21%. Happy to pay.
| holden_nelson wrote:
| Have you? Do tell.
| yazaddaruvala wrote:
| I've been to multiple Canadian ERs (2 times total) and
| multiple US ERs (2 times total).
|
| The only difference has been that _1 time_ the Canadian ER
| was busier and I waited my turn (based on an initial
| triage).
|
| I feel, during my visit, I was appropriately handled in all
| 4 locations. After leaving the hospital in Canada I was
| done. However in the US, both times a few weeks later I got
| a bill for roughly $1000, and it actively makes me think
| twice about going to the ER (even though I can afford the
| $1000). In the US, I may have skipped the ER the second
| time if I hadn't felt strongly I was having an
| appendicitis. Truly scary to think I considered not going
| based on a bit of money.
|
| If it wasn't clear, even being well off in the US, I prefer
| the overall experience in Canada.
| ozmodiar wrote:
| I have, as have members of my family, and have received
| excellent care for some fairly serious conditions. I think
| the Canadian system is under funded, and I'm sure there are
| plenty of true horror stories, but they always get
| highlighted by people who want to tear down/prevent a
| public healcare system so I feel I have to bring up that my
| family have received good and timely care. When I really
| needed healthcare I was unemployed and it was stressful
| enough seeking care without having to worry about
| insurance. Now that I'm employed I'm happy to pay back into
| the system.
|
| I value having public health care. I hope the US can come
| up with a good public system so that Canada can stop
| resting on "at least we're not like the US!"
| karpierz wrote:
| Yeah, I've also had friends and family go. No complaints.
|
| Why do you ask?
| marricks wrote:
| I have Canadian friends and it sounds better than when my
| older brother had to call their insurance company every
| months to get their anxiety meds covered because, for some
| reason, the insurance company lost the paper work for
| approving them every month. For a year.
|
| Funny because it's just the sort of thing to cause more
| anxiety in an anxious person.
|
| I'd also love hear how many Canadian cancer survivors have
| to put up gofundmes or go bankrupt for care.
| Mountain_Skies wrote:
| The quality of Canadian healthcare depends greatly on who
| is in the room having the discussion about it. If it's just
| my Canadian relatives discussing it, it's the worst
| healthcare system on Earth and too much of their taxes goes
| to funding something to provides garbage care. Once someone
| from the US enters the conversation, the quality of the
| Canadian healthcare system skyrockets. Things get really
| interesting when my cousins from Ontario who have lived in
| Florida for most of their adult lives get in the
| conversation since they're willing to call out both sides
| on their BS.
| codefreeordie wrote:
| Actually, the _median_ American has access to exceptional
| care.
|
| What is actually the case is that care available to the
| bottom quartile of Americans is below the care received on
| average in a top-tier universal care nation, and the US
| spends an absolute fortune delivering this quartile with
| substandard care.
|
| We also spend a bit more than average providing exceptional
| care to everyone else, except that we _also_ spend a truly
| ludicrous amount (compared with every place on earth except
| possibly Japan, which is still less than us but not quite as
| much less) on care for roughly everybody above the median
| during the last year of life, because we have baked some very
| expensive decisions in as the default (basically, if you don
| 't specifically ask otherwise, you will get absolute
| treatment maximalism basically until 30 days from death)
| marricks wrote:
| Why do Americans always have to play a zero sum game with
| human lives.
|
| If a quarter of our country has the worst healthcare in the
| developed world that is unacceptable.
|
| Answers like this are just begging us to give up our
| humanity.
| codefreeordie wrote:
| I have made no statements about how things should be. I
| have lots of opinions about how things should be, which I
| don't share on HN.
|
| I was making statements about how things _actually are_ ,
| since no discussion about how to make the world we want
| is likely to be meaningful or useful if there is not a
| shared view of what _is_ first.
| marricks wrote:
| And what you focus on brings about thoughts of a zero sum
| game which I called out. You can safely assume I don't
| agree with what you find most pertinent.
|
| I think a country which lets some get rich off of other's
| cancer is an abhorrent, indefensible, system.
| RHSeeger wrote:
| I'm not seeing that out of his comment. I see him saying
| we spend a ton of money, and there's the implication that
| we could be spending that money better/differently. That
| doesn't imply a zero-sum game. It does imply that the
| money available for health care is not unlimited. That's
| pretty much a fact, though.
| ryan93 wrote:
| What fraction of your income goes to the third world?
| karpierz wrote:
| > Actually, the median American has access to exceptional
| care.
|
| Is there a source for this? I'd guess that there's a
| percentile where American health care has better outcomes
| than other countries, but 50th seems pretty low.
| jorblumesea wrote:
| 60% of the US has access to "good" healthcare. Why is it ok
| to throw the under 40% under the bus?
| bitwizeshift wrote:
| Are you from Canada, or was that just an uncanny description of
| Canadian healthcare?
| vmception wrote:
| For your first paragraph, I've seen that alot.
|
| My european friends from big economies there brag about their
| insurance coverage, some working in the states with some global
| coverage plan, and as soon as I ask about something seemingly
| basic: "oh thats elective or cosmetic, why would _that_ be
| covered"
|
| I think there is a way to make it work with American
| expectations, American resources, no equivalent tax burden.
| notreallyserio wrote:
| > and as soon as I ask about something seemingly basic
|
| Do you have an example?
| arkades wrote:
| Any chance whatsoever they're going to actually reimburse doctors
| for their massive school loans, while forcing them ("no network
| restrictions") to work for this insurance plan? Especially if
| it's anything like Medicaid, and reimburses physicians and
| hospitals -below cost-.
| humanwhosits wrote:
| It's not rocket science, plenty of other countries manage to
| provide healthcare.
|
| Just remove the age limit on Medicare.
| GiorgioG wrote:
| But won't you think of the administrators at all of these
| private health insurers that would be out of their cushy jobs?
| I consulted for a "non-profit" Blue Cross Blue Shield franchise
| 15 years ago. It was rampant with nepotism and outright
| incompetence. A good chunk of our health-care "system" is just
| a giant jobs program.
| matt321 wrote:
| The country is run by the rich, and this will only pass if its
| good for the rich. Lets hope its good for the rich and the not-
| rich alike.
| lr4444lr wrote:
| Yeah, that'll be great for the state with one of if not the
| highest costs of doing business in an age of remote work: another
| payroll tax.
| docstryder wrote:
| If we go by data, the US healthcare system is the most expensive
| (not arguable) and is not even in the top 5 among developed
| countries in the most important measures. These kind of
| experiments are welcome (if they come to pass). People deserve
| better for what they pay currently.
|
| one of these references is from an US insurance company who you
| would think would be biased for US healthcare
|
| https://www.cignaglobal.com/blog/healthcare/top-10-countries...
|
| https://www.washingtonpost.com/world/2021/08/05/global-healt...
|
| https://www.internationalinsurance.com/health/systems/
| [deleted]
| masterof0 wrote:
| Would this raise the tax rates for NYers?
| FinNerd wrote:
| No, it will be paid for by the gross NYC billionaires ($400k+
| incomes) who built predatory companies, that millions love, and
| exploited workers by hiring them in contractual agreements. /s
| settrans wrote:
| You and I have different definitions of "billionaire".
| FinNerd wrote:
| I had to add a /s, Jesus
| TMWNN wrote:
| Consistently having trouble identifying sarcasm in print--
| without the "help" of idiotic illiterate marks like "/s"--
| is one of the signs of autism
| (<http://www.healthcentral.com/autism/c/1443/162610/autism-
| sar...>).
| aqme28 wrote:
| The better question is whether NYers will pay more or less
| under this plan, not whether that payment is a tax or a
| premium.
| ffggvv wrote:
| i think the original question was better
| tomatotomato37 wrote:
| Summary says it includes a "payroll assessment, similar to the
| Medicare tax"
| endisneigh wrote:
| It would be shocking if it didn't
| ceejayoz wrote:
| No, it wouldn't.
|
| The European single-payer systems pay half what we do per-
| capita, factoring in private and public spending in both
| systems. The US system is _wildly_ cost inefficient.
|
| See the chart at https://data.oecd.org/healthres/health-
| spending.htm
| rootusrootus wrote:
| Of course it'll raise tax rates. That money does come from
| _somewhere_. The real question is whether employers will
| raise salaries enough to compensate for the additional
| taxes, once they 're no longer providing insurance as a
| benefit.
| ceejayoz wrote:
| If I pay $10 in tax to save me $20 in costs, I'm not
| inclined to see that as a tax hike.
| endisneigh wrote:
| It's still a tax hike, regardless of your rationalizing
| ceejayoz wrote:
| Then a focus on tax rates instead of total cost is
| entirely disingenuous.
| endisneigh wrote:
| Not really, there are people who get great health care
| for free from their employer, and others who get a
| greatly discounted rate. Their employers will not
| necessarily savings with their employees.
|
| The result for these employees could be more taxes for
| the same or worse care they're already receiving.
|
| In aggregate I believe it's the right move but let's not
| act like everyone wins here.
| DaveExeter wrote:
| > Not really, there are people who get great health care
| for free from their employer
|
| It is not 'for free' it is part of your compensation!
| It's like saying your employer pays 6.2% + 1.45% in
| SS/Medicaid taxes 'for free'. That is part of your
| compensation.
| endisneigh wrote:
| I meant free in that you don't pay a premium, but fair
| point.
| ceejayoz wrote:
| > Not really, there are people who get great health care
| for free from their employer, and others are a greatly
| discounted rate, who will not necessarily share savings
| with their employees.
|
| Then _require_ that savings be shared.
|
| Make it a legal requirement that any company that has
| employer-provided healthcare must rebate employees the
| premium costs if they opt-out.
| endisneigh wrote:
| That makes no sense, salaries would simply be adjusted to
| compensate. The kind of bureaucracy you're proposing is
| why things are already so complicated to begin with.
| ceejayoz wrote:
| > That makes no sense, salaries would simply be adjusted
| to compensate.
|
| If you cut the salaries of employees who opt-out, but not
| those who don't, you'd be in very clear violation of the
| law I'm suggesting.
| endisneigh wrote:
| No, what I'm saying is that they wouldn't offer an
| alternative to the state run health care, as why would
| they anymore? No incentive.
| ceejayoz wrote:
| I'm not seeing the downside.
| endisneigh wrote:
| The downside is that you could be paying more taxes for
| something that you already had.
| ceejayoz wrote:
| Then perhaps it's time to unlink employment and health
| care coverage entirely.
| endisneigh wrote:
| No disagreement here.
| throw0101a wrote:
| > _It's still a tax hike, regardless of your
| rationalizing_
|
| You're already paying for health care coverage via
| monthly/annual premiums and via reduced salaries where
| your employer's portion is part of the 'total
| compensation' you get (but doesn't show up in your pay
| check).
|
| Even if the amount at the end stays exactly the same it
| may be an improvement because (a) there are no "in
| network" worries about going to the "wrong" hospital or
| getting the "wrong" doctor", and (b) it is universal
| coverage so (i) you may not have to worry about losing
| your job and losing coverage as well as (ii) you can
| change jobs and have the same (universal) coverage.
| rootusrootus wrote:
| That assumes you get the cost saving. If my company
| stopped paying for my insurance benefit and instead gave
| that money to me directly, and then I bought the cheapest
| plan I could find on the insurance exchange ... I'd be
| paying more, not less. By a fair amount.
| ceejayoz wrote:
| That seems readily fixable; make it a legal requirement
| that companies that provide employer-provided healthcare
| pay the premium to the employee if they opt out.
| rootusrootus wrote:
| In my case the premium wouldn't even come close to the
| marketplace cost. I'd be losing overall.
| ceejayoz wrote:
| https://www.peoplekeep.com/blog/which-health-insurance-
| costs...
|
| > Nationally, the analysis found that individual ACA
| Marketplace premiums are 10 percent lower than the
| average employer-sponsored insurance premium, after the
| adjustments.
|
| (Which makes sense; it's a very large risk group.)
| rootusrootus wrote:
| Okay, then congratulate my employer for beating the odds,
| I guess.
| mypalmike wrote:
| Numbers, please. This kind of claim is just mythology
| unless you have numbers to back it up.
| daenz wrote:
| >The real question is whether employers will raise
| salaries enough to compensate for the additional taxes,
| once they're no longer providing insurance as a benefit.
|
| I don't think that's even a question. The answer is no,
| they won't.
| xienze wrote:
| > The real question is whether employers will raise
| salaries enough to compensate for the additional taxes,
| once they're no longer providing insurance as a benefit.
|
| Spoiler: they won't. They'll spin not having to pay a
| premium as a pay raise.
| donatj wrote:
| I think the idea that anything that worked in Europe would
| work here as well as there without inherent corruption and
| rent seeking is laughable.
| ceejayoz wrote:
| The idea that the US is _uniquely_ corrupt and rent-
| seek-y seems laughable.
|
| There's no corruption in Italy? Eastern Europe?
| endisneigh wrote:
| The amount paid per capita and whether you would pay more
| taxes are not exclusive things.
|
| I'm not sure why people keep bringing up Europe - the USA
| is not Europe. For one doctors are paid more in the USA
| compared to Europe, medicine is more expensive here, more
| of the R and D originates here, etc
| Ekaros wrote:
| Maybe good question to ask is what makes it more
| expensive? Is it bloated administration and insurance
| system? Or is there some fundamental other difference?
| _-david-_ wrote:
| One reason is it is expensive to fund the research and
| testing and so the companies need to recoup that cost.
| They cannot in Europe and Canada due to price controls
| which means people in the US offset the cost. The US is
| basically subsidizing other Western countries.
| [deleted]
| mypalmike wrote:
| "Critics of drug price regulation argue that free market
| pricing strategies and higher prices in the United States
| are instrumental to innovation. One might therefore
| expect the United States to be the most innovative given
| that it is the only country with a predominantly
| unregulated pharmaceutical market. However, US
| pharmaceutical innovation appeared to be roughly
| proportional to its national wealth and prescription drug
| spending. Our data suggest that the United States is
| important but not disproportionate in its contribution to
| pharmaceutical innovation. Interestingly, some countries
| with direct price control, profit control, or reference
| drug pricing appeared to innovate proportionally more
| than their contribution to the global GDP or prescription
| drug spending."
|
| https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866602/
| heavyset_go wrote:
| A lot of that R&D is already funded with our taxes via
| the NIH.
| bdzr wrote:
| A significant portion is not. Clinical trials are
| unbelievably expensive, see
| https://www.science.org/content/blog-post/drugs-come-
| compreh....
| throw0101a wrote:
| > _The amount paid per capita and whether you would pay
| more taxes are not exclusive things._
|
| You're already paying for health care coverage via
| monthly/annual premiums and via reduced salaries where
| your employer's portion is part of the 'total
| compensation' you get (but doesn't show up in your pay
| check).
|
| Even if the amount at the end stays exactly the same it
| may be an improvement because (a) there are no "in
| network" worries about going to the "wrong" hospital or
| getting the "wrong" doctor", and (b) it is universal
| coverage so (i) you may not have to worry about losing
| your job and losing coverage as well as (ii) you can
| change jobs and have the same (universal) coverage.
|
| It'd be a deal even if it costs exactly the same.
| newaccount2021 wrote:
| ldayley wrote:
| With California and New York both exploring statewide single
| payer healthcare it looks like the Overton window is moving
| closer to legitimate discussion of a nationwide single payer plan
| in the US. It'll be interesting to watch, since this is such a
| hot-button topic here on many levels.
| vmception wrote:
| as long as these plans can negotiate and also use their market
| power to reduce the prices that healthcare services charge to
| Americans, but starting within their jurisidction
|
| a significant portion of the consensus failings have been
| because simply having insurance for all is just a bandaid, and
| this has been an accurate criticism of one party's tax and
| spend trend whether that seems like a conversation derailing
| political statement or not
| lotsofpulp wrote:
| It is dead in the water. The Republicans show no sign of
| supporting broad non means tested or non age gated taxpayer
| funded healthcare, and they hold the cards in the US Senate.
|
| On the state level, any broad based benefit that does not
| discriminate is also futile because benefit recipients can move
| into the state and payers for the benefits can move out of the
| state.
|
| See Vermont for the previous trial of this:
|
| https://en.wikipedia.org/wiki/Vermont_health_care_reform
|
| It the same problem with homelessness, education, and mental
| healthcare (a subset of healthcare). Without a border to limit
| the ratio of net benefit recipients to net payers, the numbers
| will not work out.
| irrational wrote:
| You really think people are going to flee NYC and the large
| cities in CA over this?
| mywittyname wrote:
| OP sounds to be arguing the opposite. One lives in a low
| tax state while earning money / paying taxes, then retires
| to a rural part of NY / CA to receive tax-payer-backed
| benefits without paying for them.
| pkaye wrote:
| Retirees usually use Medicare.
| exhilaration wrote:
| Having a bunch of (medicare-covered) retirees (with no
| school-age kids) spending their (taxable) social security
| income in NY / CA sounds pretty great. Much better than
| losing them to Florida or Arizona. Bonus if the states
| get to tax their estates in the end.
| [deleted]
| lotsofpulp wrote:
| The fact that they are Medicare covered means the
| retirees will choose to retire in lower tax
| jurisdictions. They do not need state governments to
| provide healthcare.
| mynameishere wrote:
| I think he means people who have enough money at, say, 40
| years old, to pay for everything but health insurance. I
| can see the temptation myself, since insurance as you get
| into your 50s can be 2000/month or more. If NY State pays
| that while I wait for Medicare to kick in, hey, FIRE!
| ceeplusplus wrote:
| Half of California's tax revenue comes from the top 1%
| [1]. Medicare retirees are almost guaranteed to not be
| part of that 1%. You're talking huge tax revenue losses
| here if the 1% do decide to leave.
|
| [1] https://lao.ca.gov/LAOEconTax/Article/Detail/7
| gleenn wrote:
| Anecdata but I personally know more than a few people who
| moved to Nevada to avoid California taxes, so yes.
| toomuchtodo wrote:
| California is the fifth largest economy in the world. New
| York State's GDP is roughly $1.5 trillion, 8 percent of the
| U.S. total. They are resourced at levels of entire OECD
| countries that offer universal healthcare.
|
| If Congress can't get its shit together, states that can
| should.
|
| https://www.politifact.com/factchecks/2015/sep/01/dan-
| gecker...
|
| https://web.archive.org/web/20160107120644/https://www.who.i.
| ..
| newaccount2021 wrote:
| lotsofpulp wrote:
| 30% of the US federal budget is healthcare spending.
|
| https://www.usaspending.gov/explorer/budget_function
|
| And that is only because a ton of people do not actually
| get healthcare, either because deductibles dissuade them or
| they do not pass the means testing to get enough subsidies
| to buy Medicaid or healthcare.gov insurance.
|
| And that is because Medicaid severely underpays doctors to
| the point that if you visit a US city subreddit, one of the
| frequently asked topics is "where can I find a doctor that
| will accept Medicaid".
|
| I think this issue can be too big for even NY or CA. It
| seems like it is for the US federal even, such that the
| political will only exists to provide healthcare via
| extreme price segmentation/discrimination. But most
| importantly, you can surely have your high risk pregnancies
| and hemophiliacs and cancer or whatever other high cost
| patient population move to the state, and the price tags on
| those patients is nothing to sneeze at.
| toomuchtodo wrote:
| Very broad strokes, doctors in the US are overpaid and
| conservatives legislated Medicare can't negotiate drug
| prices. Lots of room to drive down costs. Spending is
| high because of a dysfunctional system driven by profit
| instead of care.
|
| https://www.npr.org/sections/money/2019/03/12/702500408/a
| re-...
|
| https://www.healthaffairs.org/doi/full/10.1377/hlthaff.20
| 10....
|
| https://www.bostonglobe.com/2021/10/25/opinion/let-
| medicare-...
|
| https://www.brookings.edu/research/a-dozen-facts-about-
| the-e...
|
| https://www.commonwealthfund.org/publications/issue-
| briefs/2...
| programmertote wrote:
| Agree with the part about doctors being overpaid in the
| states. My wife is a 3rd year resident of a fairly well-
| known hospital system in one of the biggest metro areas
| of the US. We always feel lucky that she is a doctor
| because we know that she will make $250K+ (more like
| $300K/year if she choose a hospital in a rural area) as
| an internal medicine doctor (hospitalist/attending). My
| wife might go for oncology fellowship and that might put
| her earnings close to $400K+/year after 3 years of
| fellowship training (during the fellowship, she will make
| ~$80-90K/year). We get very good health insurance from
| her hospital since she started her residency there. I
| myself quit medical school after 2 years because I hated
| the way I had to study to get good grades there (a lot of
| rote memorization). But looking back, I regret quitting.
|
| Both my wife and I agree that if we ever have a kid, we'd
| encourage him/her to at least consider medicine as
| his/her profession (assuming that the US healthcare
| system stays the relatively same). We are NOT the only
| ones. There are so many doctor friends of ours whose
| parent(s) are doctors. Our friends also think the same as
| us (that they'd encourage their kids to consider medicine
| as a profession).
| collegeburner wrote:
| We already have a shortage of doctors and it is very
| expensive to become a doctor. How will paying doctors
| less help this? We need to reduce requirements for
| becoming a doctor and have "tiers" so people who just do
| family doctor things only need to know family doctor
| things.
|
| Prescription drug spending is less than 20% of medicare.
| Negotiating prices might help but taking that 20% to 10%
| still leaves healthcare as a very very large expense
| (source
| https://www.commonwealthfund.org/publications/issue-
| briefs/2...).
| omegaworks wrote:
| We could forgive the school debt of existing doctors and
| pay the entire cost (with appropriate cost controls) of
| medical school for new doctors.
| [deleted]
| tryptophan wrote:
| > We need to reduce requirements for becoming a doctor
| and have "tiers" so people who just do family doctor
| things only need to know family doctor things.
|
| The fact that you think family medicine is about "just
| knowing family doctor things" tells me all I need to know
| about your level of medical knowledge.
|
| Family medicine is arguably the field with the highest
| knowledge ceiling, because they have the first encounter
| with literally anything the patient can present with.
|
| Lowering standard and having NPs write adderall(have you
| heard the news about those ridiculous ADHD online
| clinics? btw people don't seem to appreciate that
| adderall is functionally meth) and antibiotics for
| everyone they set their gaze upon is not the right way to
| improve healthcare.
| lotsofpulp wrote:
| Sure, and the US doctors I know tell me they tell their
| kids to NOT become doctors due to the high education cost
| (not just in money, but in years) relative to quality of
| life at work and compensation, which are both decreasing.
|
| There's a myriad of factors here, but at the very root of
| it all is that there are a lot of people in the US that
| could use healthcare they cannot afford, but I do not see
| the political will for the wealth transfer required to
| get it to them.
|
| Even in the countries that do have free healthcare, I
| believe there are cracks forming due to decreasing
| proportions of the population of young people (net labor
| suppliers into the "system") versus the increasing
| proportions of populations of older people (net
| recipients of labor).
| maxerickson wrote:
| Part D is federal subsidies for private insurance, the
| companies that offer those plans choose what drugs to
| cover and negotiate prices and so on.
|
| If you don't want private companies to be involved in
| that coverage that's fine, but the whole Medicare can't
| negotiate prices is such a weak talking point,
| obfuscating the issue for cheap points.
| mullingitover wrote:
| There was a bill in California pretty recently, it was
| killed without a vote in the full chamber [1].
|
| The window-breaking-and-repairing industry is too powerful
| for us to stop it, unfortunately.
|
| [1] https://www.npr.org/2022/01/31/1077155345/california-
| univers...
| [deleted]
| rootusrootus wrote:
| Something is going to have to change. As it stands, there isn't
| a plan on the national insurance exchange that I can buy that's
| even remotely as cheap as my company's plan (actual premium,
| not just the fraction paid for by employee).
| lettergram wrote:
| Probably because your company can negotiate and control the
| population characteristics (unlike the exchange). Or is self-
| insured, meaning they aren't profit motivated.
|
| Insurance on average is always more expensive than not having
| insurance on average. The question is given that risk, how
| much of a premium can / will insurance companies take. Turns
| out they like high profits and low risk.
| akomtu wrote:
| Are health insurance companies allowed to discriminate
| customers by their health status, that includes age? With a
| good deal of populace morbidly obese and not even bothering
| to exercise, it's expected that healthy 25 yo are going to
| pay crazy insurance payments. Corps, on the other hand,
| absolutely do discriminate by all sorts of characteristics
| and insurers know what they are signing up for. Offer
| health insurance tiers by age and BMI and watch premiums
| getting reasonable again (for some).
| lotsofpulp wrote:
| No. Per the Affordable Care Act, since 2010 health
| insurance companies can only price insurance based on
| age, smoking status, and location. And they must offer
| insurance to all.
|
| https://www.healthcare.gov/how-plans-set-your-premiums/
| DaveExeter wrote:
| > Offer health insurance tiers by age and BMI and watch
| premiums getting reasonable again
|
| That's not the way health insurance works. The way it
| works it that the young and healthy are overcharged and
| that overcharge is given to the old and unhealthy.
| DesiLurker wrote:
| its would be interesting to see a deep-blue state coalition
| single payer system. that might pave the way to a national
| version of it.
| ars wrote:
| Massachusetts may try it as well: https://masscare.org/
|
| It'll be a very interesting experiment, if it works, other
| states will copy it. If it fails wealthy people will leave
| those states for places with lower taxes, and poorer people
| will move in to gain free health care.
|
| There's a reason the most populous states (CA, NY, MA) are the
| ones trying it first, and it's not because it's cheaper.
| lotsofpulp wrote:
| Vermont tried it first, and it is tiny, and stopped it
| because it was unaffordable. I would say the correlation is
| with how Democrat a state is, not how populous it is. And
| while it is good for political campaign slogans, I highly
| doubt CA/NY/MA legislators actually vote it into law.
| TMWNN wrote:
| >Massachusetts may try it as well: https://masscare.org/
|
| Massachusetts has had 98% health care coverage for more than
| 15 years. (The only countries in the world with more than
| that are those, such as the UK, in which no membership card
| is needed for receiving care.)
| lotsofpulp wrote:
| Health care coverage with a deductible and copays is not at
| all similar to taxpayer funded healthcare such as that in
| the UK.
| airstrike wrote:
| I can't help but read "massacre" when I see "masscare"...
|
| As they say, naming things is harder than you'd think
| lettergram wrote:
| Why would you want it nation wide?
|
| Even if you "support it", I'd much rather watch the
| implications from the various experiments across states. Then
| we can select the best option.
|
| Personally, I'd like to see some states ban healthcare
| outright. Others have full coverage and everything in between.
| Then wait 10 years and we can see the results. I strongly
| suspect there would be states willing to do this.
| [deleted]
| arcbyte wrote:
| Yep. I vehemently oppose federal Healthcare initiatives but
| im very receptive to state options.
| codefreeordie wrote:
| presumably, you don't actually mean "ban healthcare" so much
| as some version of "prohibit government spending on
| healthcare" or somesuch?
|
| I'm pretty sure there's actually no constituency for
| outlawing the practice of medicine.
|
| Or maybe you're actually the misanthrope that I sometimes
| pretend to be?
| kbenson wrote:
| > Why would you want it nation wide?
|
| They didn't say they did, they said we're closer to having a
| legitimate discussion.
|
| But to answer your question, if it's better, we might want it
| nationwide for similar reasons we have a national minimum
| wage and national child labor laws. For some things making
| sure there's a lower bound that _everyone_ can rely on is a
| large part of the benefit, so inconsistent rules across the
| nation don 't allow for a large portion of the benefit to be
| realized.
|
| Whether this is one of those cases is something we'll
| hopefully get some more data on.
| airstrike wrote:
| This argument makes no sense. If you're really interested in
| "selecting the best option", there can always be a federal
| option complementing state "experiments".
| tenpies wrote:
| Exactly.
|
| US salaries for healthcare are the best on the planet,
| period.
|
| The comparison (and to be fair, this is a very high level)
| paints an extremely clear picture:
|
| United States $313,000
|
| Germany $163,000
|
| United Kingdom $138,000
|
| France $108,000
|
| Per: https://www.worldatlas.com/articles/countries-with-
| highest-p...
|
| So yes, I absolutely want to see how many physicians stick
| around if you tell them "your salary will now be half and
| we're maxing our your workload". Alternatively, I want to see
| how long the State's finances last if they say "we'll pay the
| national market rate for your services and we're now maxing
| our your workload".
|
| And even then I don't want 10 years, I want a generation or
| two. Even pre-COVID we had multiple surveys indicating that
| 60-70% of doctors would not recommend becoming a doctor. I
| want to see how that number changes as States run their
| experiments.
| throwaway2214 wrote:
| > "your salary will now be half and we're maxing our your
| workload"
|
| should be fine if they pay their student loans no? isnt
| that the main reason the salaries are so high? cost of
| living + debt
| rhexs wrote:
| Paying off 200K in debt with a 300K minimum salary is
| pretty trivial unless you immediately qualify for a 4
| million dollar mortgage, buy a BMW, then get divorced six
| times after med school.
| TuringNYC wrote:
| cost of living isnt the reason for high salaries in
| Medicines. Unlike tech, salaries in medicine _increase_
| as you go to rural and /or underserved areas. It is
| driven by supply/demand and quality of life in urban vs
| rural areas.
| bdzr wrote:
| Sort of, the supply of physicians is artificially limited
| by the AMA - which dictates how many physicians there
| are. That keeps the cost of physicians nice and high.
| heavyset_go wrote:
| > _isnt that the main reason the salaries are so high?_
|
| It's because the NIH limits the amounts of medical
| residencies in the country, and to become a doctor with a
| license to practice, you must have completed residency
| somewhere. The amount of doctors in the US are kept at
| low numbers because of this.
| lettergram wrote:
| I thought it was the AMA, but yeah I know about this and
| agree. This is the real problem
| holden_nelson wrote:
| I didn't know that. Why does the NIH limit the number of
| residencies?
| rootusrootus wrote:
| This will be a tough problem to solve. We could start by
| eliminating the AMA.
| duncan-donuts wrote:
| Ban healthcare? Like make it illegal to receive care or are
| you saying have no concept of health insurance and everything
| is out of pocket?
| vdnkh wrote:
| > Personally, I'd like to see some states ban healthcare
| outright. Others have full coverage and everything in
| between. Then wait 10 years and we can see the results. I
| strongly suspect there would be states willing to do this.
|
| This is the most HN comment I've ever seen
| kbenson wrote:
| I'm not even sure what they mean by ban "healthcare"
| (insurance, doctors, hospitals?), and I can't decide if
| that makes me agree with you more or less.
| lettergram wrote:
| I meant health insurance, but gonna just leave it lol
| [deleted]
| Workaccount2 wrote:
| I wonder if we could get an interstate cluster healthcare plan.
| NY, MA, CT, NJ joined together (ok RI, you too) certainly have
| the economic firepower and population numbers to get a good
| system going.
| rootusrootus wrote:
| "Died in committee" I assume will be the final result, official
| in a couple weeks.
| vmception wrote:
| ha lol, one sponsor, in committee
|
| yeah I don't consider this kind of thing news, but it did open
| a conversation that I wanted to have
| susanasj wrote:
| maybe I'm misunderstanding but I see at least 4-5 cosponsors
| that are members of the health committee?
|
| not saying I think this will come to pass necessarily but
| there's like 30 cosponsors listed and the NY State Senate is
| 63 members.
| vmception wrote:
| That is a lot of cosponsors, I was reading the page wrong
|
| (Govtrack's site and Congress houses have a slightly
| different format for showing sponsors and cosponsors
| together)
| susanasj wrote:
| understandable, I didn't realize it had this many
| cosponsors and I live in NY.
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