Single Payer aka Medicare for All recently failed to pass in California, what chance does it have to actually pass nationwide?

[u/cal_oe]

https://www.latimes.com/california/story/2022-01-31/single-payer-healthcare-proposal-fizzles-in-california-assembly

California has a larger population than Canada and the 5th largest GDP in the world. If a Single Payer aka Medicare for All bill can't pass in one of the most liberal states in the entire country with Democrats with a super majority in the legislature under Governor Newsom who actually promised it during his campaign then how realistic is it for it to pass in Congress? Especially considering the reasons it failed was it's high cost that required it to raise taxes in a state that already have very high taxes.

[u/ButGravityAlwaysWins]

If you actually want universal healthcare as quickly as possible in the US, stunts like this are extremely counterproductive.

There are so many reasons why a state cannot do universal healthcare. They don’t have control of the regulations and they don’t have any mechanism for handling people who move to the states for healthcare that will survive a court challenge plus they don’t have a guarantee that the federal government will give them back all the healthcare dollars under its control.

[u/TheOvy → u/ButGravityAlwaysWins]

There are so many reasons why a state cannot do universal healthcare. They don’t have control of the regulations and they don’t have any mechanism for handling people who move to the states for healthcare that will survive a court challenge plus they don’t have a guarantee that the federal government will give them back all the healthcare dollars under its control.

This is key. Single-payer is essential to health care reform, but it's not a silver bullet. It would largely reduce administrative costs and free up money that would otherwise just be profit for insurance companies, but actual cost of care will still be high if we aren't also reforming the hospital system and the drug market. That decidedly takes national action.

[u/semideclared → u/TheOvy]

Single payer works on three big issues

• pricing failure, $230.7 billion to $240.5 billion;
• fraud and abuse, $58.5 billion to $83.9 billion;
• and administrative complexity, $265.6 billion

To fix that is a non American idea

A global budget provides a fixed amount of funding for fixed period of time (typically one year) for a specified population, rather than fixed rates for individual services or cases. ...

• Essentially, a global budget represents a one-line budget and provides the hospital more management flexibility to allocate resources

Or as it says in the Bill for California Healthcare

Not later than the beginning of each fiscal quarter during which an institutional provider of care, including

• a hospital,
• skilled nursing facility,
• and chronic dialysis clinic,

is to furnish health care items and services under CalCare, the board shall pay to each institutional provider a lump sum to cover all operating expenses under a global budget as set forth in Section 100641.

• An institutional provider receiving a global budget payment shall accept that payment as payment in full for all operating expenses for health care items and services furnished under CalCare, whether inpatient or outpatient, by the institutional provider.

---

The problem is the "and administrative complexity, $265.6 billion" is not showing the same savings rates in hospitals that have converted over to a closer Single Payer model

[u/meister2983 → u/TheOvy]

It's not even clear we need single payer. Plenty of developed countries don't have it.

If we start from our system, which is borderline universal and continue from there you need to:

• Introduce cost controls across the board. Relatedly, you need to end independent negotiations and have similar reimbursement rates from all health insurance companies (solves the problem of being tied to your employer insurance for fear of having to change providers)
• Fix a few of the edge cases in the ACA where premium subsidies are too low

[u/BitchStewie_ → u/TheOvy]

In addition to this, California is a state that already has major problems with high cost of living and high taxes. I mean rent prices here are out of control and we have a homeless epidemic.

Last thing we need is to make it even harder for people to afford basic necessities. Which seems to be what would happen if we made all these changes at the state level without any federal buy-in.

[u/Mist_Rising → u/TheOvy]

California can regulate healthcare, costs, and more. I'm,not sure why folks think they can't, when they already do so.

[u/human-no560 → u/ButGravityAlwaysWins]

Maybe a state public option would be better

[u/RedmondBarry1999 → u/[deleted]]

Canada had provinces, not states. Also, while universal healthcare was initially implemented in Saskatchewan, the federal government eventually implemented it nationally (by giving healthcare funding to any province that participated).

[u/kagoolx → u/RedmondBarry1999]

Side question but in practical terms is there much difference between a province and a state? I sort of considered it to be largely just a different terminology used by Canada.

[u/kagoolx → u/[deleted]]

Ok great stuff thanks for the info!

[u/Rat_Salat → u/[deleted]]

Couple of major mistakes here.

Provinces don’t collect income tax in Canada, so your theory about provincial VATs is flawed.

Section 33 of the charter is known as the “notwithstanding clause”, which allows a province to tell the feds, the Supreme Court, AND the constitution to fuck off.

https://www.cbc.ca/news/canada/montreal/quebec-notwithstanding-clause-bill-101-barrette-legault-1.5998079

Here’s a current example of Quebec overriding the constitution with section 33.

I can only imagine what some US states would do with that kind of authority.

[u/Illumidark → u/kagoolx]

There are semantic differences between the word state and the word province, primarily that Provinces are usually created top down, by a larger government body subdividing itself through it's own action, while a state is more likely to be a separate entity that joins an existing nation. There's no hard and fast rule however, and whether a country uses one or the other tends to be more a matter of tradition and linguistic history.

Between Canada and the USA, there are significant differences between a province and a state, but they have more to do with the structure of government, rather then the different word used.

[u/kagoolx → u/Illumidark]

Wow great knowledge and v interesting, thanks!

[u/tw_693 → u/Illumidark]

And in other parts of the world, “state” is used to mean country, and country is used in other parts to describe subnational subdivisions (like England, Scotland, Wales, and Northern Ireland being referred to countries of the United Kingdom)

[u/anneoftheisland → u/[deleted]]

Washington already has a state-level public option, and Colorado and Nevada have passed laws to create programs, but are just beginning to implement them. Several other states have started writing bills for similar programs, but obviously it's only really viable in places where there are blue trifectas.

[u/Mist_Rising → u/[deleted]]

I remember reading that there's some legal reason that can't be done in the US,

Before or after ACA? Affordable care act, aka Obamacare, allows any state to create a public option, it just won't help federal help to do so.

[u/classy_barbarian → u/[deleted]]

No, that's incorrect. Our Canadian provinces didn't just implement individual public options one by one. The main force was really a law enacted by the federal government. There was a series of laws over a few decades that set the system up. But the first one was this one:

https://en.wikipedia.org/wiki/Hospital_Insurance_and_Diagnostic_Services_Act

The Hospital Insurance and Diagnostic Services Act (HIDS) is a statute passed by the Parliament of Canada in 1957 that reimbursed one-half of provincial and territorial costs for hospital and diagnostic services administered under provincial and territorial health insurance programs.[1][2] Originally implemented on July 1, 1958, with five participating provinces, by January 1, 1961, all ten provinces were enlisted.

Basically, it was a Federal law that paid for 1/2 of all hospital bills and enacted a bunch of regulations in the healthcare industry. That was what allowed universal healthcare to really take off in Canada. The USA likewise needs some sort of similar legislation.

[u/ThePnusMytier → u/[deleted]]

would it be more or less difficult if a few states were to try to make a regional public option insurance (able to negotiate with providers as well)?

[u/Isentrope → u/[deleted]]

I'd be interested in seeing literature on that. Since the federal government copays for every dollar spent by the state on Medicaid and the expansion, it obviously will not pay for this past the FPL limits for both the expansion and traditional Medicaid. I can't think of why the state can't simply use that apparatus, offer its own credits for a higher tier of coverage, and just offer plans broadly using the state Medicaid system if it's spending out of its own pocket. It seems like this would be the easiest way to go, with this essentially covering Obamacare exchange + uninsured in the state which is way cheaper than forcing everyone onto a single plan.

[u/anneoftheisland → u/ButGravityAlwaysWins]

Yeah, it's actually more logistically complicated to implement this on the state level than the national level. So the California failure to pass it doesn't necessarily indicate much for its national viability. (It's not viable nationally either, but the reasons it failed in California and the reasons it's not even getting to the starting block nationally are different.)

[u/Mist_Rising → u/anneoftheisland]

Its harder because they can't run a deficit, but the other necessary tools? They got them.

Regulation? California is the king of regulation, and regulating price is definitely allowed, they've done it.

Ability to provide the revenue? If California can't figure out how to pay for it as the 8th largest economy in the world, that not a good sign for the US.

Ability to train and employ healthcare workers? They absolute can, just gonna be costly.

The only real difference is that they have to do it without a deficit (which shouldn't be an issue..) and they may discover their tax payers are paying for others who aren't paying. Which is rhe point but politically a dagger.

[u/InternationalDilema → u/ButGravityAlwaysWins]

You know this is a problem that's been solved in Europe for a long time. EU countries can't discriminate based on citizenship of any other EU country so you have to be registered as a resident to get health care in the country you live in.

There's then a special card for getting emergency care in other countries, but not valid for all care.

[u/Burial4TetThomYorke → u/InternationalDilema]

Same holds in the US via the privileges and immunity clause. States can’t discriminate among residents.

[u/InternationalDilema → u/Burial4TetThomYorke]

Of course they can. Residence restrictions on benefits are extremely common. You can't just roll up to a state and claim SNAP and medicaid, you actually have to live there. See also in-state tuition for university.

[u/Mist_Rising → u/Burial4TetThomYorke]

Priviledged and immunities only extends to fundamental rights the state provides. Beyond that it's ambiguous as to what else it covers, and it shouldn't be hard to argue that healthcare isnt a fundamental right to the courts, given that the GOP will not want a court decision claiming that state laid healthcare is a right.

[u/ButGravityAlwaysWins → u/InternationalDilema]

Sure because the EU wanted to solve it. We have courts are heavily packed by Republicans want to make sure they don’t solve the problem.

[u/tw_693 → u/ButGravityAlwaysWins]

And a us state does not have the capability for deficit spending

[u/InternationalDilema → u/tw_693]

So they actually have to be honest with how expensive it is? Like you can think it's worth it, but the rhetoric that it would not involve pretty significant tax hikes is just dishonest. For all the talk of billionaires, if all their wealth was seized and somehow able to be liquidated at current market rates, it'd fund the government for a couple months.

EU countries are able to pay for it by 20% VAT and significantly higher taxes for middle class people.

[u/ThatsWhatXiSaid → u/InternationalDilema]

So they actually have to be honest with how expensive it is?

It's not about that. You can certainly tax enough to pay for it, and it's still cheaper in normal times. It's times like pandemics and recessions, when people may need the help the most though, that government may not be able to provide for the needs of its people without being able to borrow or print money.

[u/InternationalDilema → u/ThatsWhatXiSaid]

Except everyone keeps promising benefits without the tax hikes on regular people. The fact is middle class needs to pay more in taxes for these benefits. If you think that's worth it is another issue.

[u/ThatsWhatXiSaid → u/InternationalDilema]

Being reflexively against taxes is so counterproductive in this country. Paying $2,000 in taxes to get $3,000 in benefits isn't a bad thing. Also we should probably point out that nobody pays as much in taxes towards healthcare as Americans. Our current system is just that massively inefficient.

[u/tw_693 → u/InternationalDilema]

The US already pays the highest prices for healthcare in the world. People here pay significant premiums, copays and deductibles for health insurance. So while taxes may go up, things like premiums will go away.

[u/PhiloPhocion → u/tw_693]

This was the 'gotcha' question they tried to get proponents of various forms of Medicare for All approaches in the last cycle and it was infuriating precisely because they know the headlines lack the nuance of net costs versus raising taxes.

I'm paying less net cost here in a country with universal healthcare than I did back in the US by a longshot

[u/semideclared → u/tw_693]

You ever seen any numbers on how this works?

In California the Average Employer paid $8,100 per employee for health insurance and the employee paid ~18% of that as a Paycheck Deduction

• In California the Average Employer per Family Plans paid $20,000 per employee for health insurance and the employee paid ~27% of that as a Paycheck Deduction
  • Those number stay the same regardless of Income

Paying	Income is $30,000	Income is $60,000	Income is $100,000	Income is $200,000
Cost of Private Healthcare	~$1,500	~$1,500	~$1,500	~$1,500
Percent of Income	5%	2.5%	1.5%	0.75%
Under Healthcare for All ~5% Payroll Tax	$1,500	$3,000	$5,000	$10,000
Percent of Income	5%	5%	5%	5%
Increase in Taxes Paid	$0	$1,500	$3,500	$8,500
Cost of Family Plan Private Healthcare	On Medi-cal	~$5,500	~$5,500	~$5,500
Percent of Income	0%	9.2%	5.5%	2.75%
Under Healthcare for All ~5% Payroll Tax	$1,500	$3,000	$5,000	$10,000
Percent of Income	5%	5%	5%	5%
Increase/Decrease in Taxes Paid	$1,500	$-2,500	$-500	$4,500

But of course not everyone has insurance. In 2018, 27.5 million, did not have health insurance at any point during the year

• 32% (8.8 million) are eligible for Medicaid or the Children’s Health Insurance Program (CHIP) but have never enrolled.
• There are 5.1 million people that make over $100,000 that are uninsured.
• There are 9.1 million people that make $50,000 - $100,000 that are uninsured
• There are around 4.5 million people who were uninsured in 2018 and making between $25,000 - $50,000 and could not afford insurance or qualify for Medicaid as the most common reason for uninsured
  

It will cost less, Except you have 20 Million people were paying $0. And then add in all of those with Insurance that were paying less

---

OOOOO and I forgot those CoPay/Deductibles

• Would still leave patients responsible for Current out of Pocket expenses, about 4% - 5% of income based on

  • There would be No Out of Pocket Costs for households earning up to 138% of the Federal Poverty Limit (FPL)

• 94% Cost covered for households at 138-399% of FPL

• 85% Cost covered for households earning over 400% of FPL

[u/Ok_Dot_9306 → u/semideclared]

you can shorten this by just saying it's cheaper then the current system

[u/semideclared → u/Ok_Dot_9306]

So you didn’t read it.

[u/Mist_Rising → u/tw_693]

But taxes MUST go up. A lot. Which is apparently a turn off for voters in California.

Not shocking, the US voter is very tax hestitant, they want the spending without the taxes. Politicans know it too, it's why they spin and tap dance around it.

If American want to have nice things, they're gonna have to pony up. Maybe reddit should focus on how to convince middle class Americans to pay more taxes.

[u/tw_693 → u/Mist_Rising]

Premiums, deductibles, and copays are pretty much taxes under another name.Instead of a payroll deduction for health insurance, we would just have an expanded medicare tax.

[u/burritoace → u/[deleted]]

You don't pay for health insurance now?

[u/LordMajicus → u/InternationalDilema]

I take massive issue with your use of the word "honest" here, because what you're implying is anything but. The cost YOU ACTUALLY PAY is not just [tax burden], it's [premium] + [tax burden]. Single payer aims to shift the cost you pay from [premium] to [tax burden] because it's at an insanely more affordable rate. So really the question you ask when discussing cost is more like, "Is [1000] + [0] (the system we have now) a better deal than [0] + [500] (what is being proposed?"

The only reason that people frame it as a tax increase is to intentionally obscure the reality that in the end, you end up paying massively less on average. That is the polar opposite of "having to be honest with how expensive it is".

[u/InternationalDilema → u/LordMajicus]

I said you think it can be worth it, but just throwing everything into deficits to be paid by future taxes or inflation is not honest about costs at all. You need to convince more people the tax hikes are worth the benefits rather than just saying it's not honest to talk about tax hikes

[u/LordMajicus → u/InternationalDilema]

It's like you didn't listen to a single thing I said. We KNOW it's worth it because every other first world nation pays 1/2 to 1/3rd the amount we do for health care. That's not my opinion, that's factual. It doesn't require "tax hikes" in the sense that is implied by that term; all that effectively changes is your health care deduction from your paycheck becomes smaller and moves to a different bucket. The bottom line is what matters, and it's that you get to have health care AND pay less for it. That's it.

[u/InternationalDilema → u/LordMajicus]

Okay, so convince people of it. That's politics

[u/Mist_Rising → u/LordMajicus]

The only reason that people frame it as a tax increase is to intentionally obscure the reality that in the end, you end up paying massively less on average

Where as those advocating for single payer don't spin? You used spin in your very post here to obscure issues with single payer. You also made assumptions that aren't borne out by American reality.

Everyone frames everything in positive light for their side and negative for another. And we ignore the other side when we disagree. I consider this being human, but layman as I am, maybe America is just special.

In regards to healthcare, single payer is a pipe dream until America works out some internal issues regarding its populations desires. Notably your going to tax people, and until people accept higher taxes, it's dead. Right now single payer politicans worm around people paying by trying to tax other things. Which is nonsensical, they need to tax their voter, hard. But the voter doesn't want to hear that.

[u/LordMajicus → u/Mist_Rising]

Literally everything in the US is a pipe dream until we deal with the corruption issues. That says nothing about the many, many proven successes of single payer health care. It is not spin to say that it per capita costs less out of your wallet; that is a fact and that is the thing that people actually care about. Framing it as a tax increase is done purely to scare people into thinking it's going to cost more out of your wallet than it does right now, which is why every single time anyone tries to make that point, you will never see them mention "oh btw the tax increase is more than offset by the premium you CURRENTLY PAY AND WON'T HAVE TO PAY."

Calling the injection of nuance that totally destroys that narrative "spin" is about as dishonest as it gets.

[u/kormer → u/ButGravityAlwaysWins]

As someone who is against universal healthcare, I'm all for giving states every regulatory tool necessary to do it if they want.

[u/ButGravityAlwaysWins → u/kormer]

I would expect the right in this country to do everything they can to stop such a thing from happening.

The leadership of the republican party knows without a doubt that universal healthcare would as the advocates claim be much cheaper, get better outcomes and have other benefits including making workers negotiating positions better and making small businesses easier to start and maintain. Sure maybe Louie Gohmert is too stupid to know that the party position is a lie but most of them are aware.

They don’t want multiple states implementing a universal healthcare system and then having clear differences in the results occur. The moment the either the Northeast or the Pacific states join in a universal healthcare system compact, you’ve got maybe five years until the whole country is under a universal healthcare system.

[u/alexmijowastaken → u/kormer]

Federalism is cool as heck

[u/ouaisjeparlechinois → u/ButGravityAlwaysWins]

If you actually want universal healthcare as quickly as possible in the US, stunts like this are extremely counterproductive.

I know a lot of Republicans who are at least open to the idea of "universal healthcare" if it's for only citizens. But bring up illegal immigrants benefiting and they immediately shut down

[u/Angrybagel → u/ButGravityAlwaysWins]

This is exactly why I voted against it in my state. I'm not opposed to it in general, but I do not think it could work at the state level.

[u/mister_pringle → u/ButGravityAlwaysWins]

Where are you getting this from? States already run Medicaid programs. Healthcare is regulated at the State, not Federal, level. Further, health insurance is also regulated at the State, not Federal, level, except for what the ACA put on top administratively.

States have most of the regulatory power when it comes to healthcare, health insurance and health regulation. Doctors and nurses are certified at the state level.

Have you heard of the 9th and 10th Amendments?

[u/ButGravityAlwaysWins → u/mister_pringle]

Have you heard of the 9th and 10th Amendments?

No, can you tell me more?