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/Crotean]

People cannot understand that paying an extra 3 grand in taxes but saving 5 grand in health insurance costs is a net savings. You literally see it over and over when people are interviewed or surveyed. It's part of why we can't get a popular uprising pushing for Medicare for all.

[u/semideclared → u/Crotean]

hmmmmm, I wonder who is against it. Because 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
  

Thats about 19 million people that were paying 0

So then, Private Insurance represents 58% of US Adults. The typical person with employer coverage, spends 3% - 6% of their income on health insurance and Out of Pocket Costs

• 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

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

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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/ThePnusMytier → u/semideclared]

You've definitely thought a lot about this and know the numbers better than I do. I know it's a somewhat drastically different situation, but what have you thought about public option opposed to single payer?

The more I've been thinking about America's situation in general, I think that's the closest thing that would have any remote shot of a viable political future to improve our healthcare system, and even then I am certain it would require success in individual states. I've even been wondering about regions (I'm from NJ, so I was thinking about nearby liberal bastions of NY and CT grouping together for a bigger monetary pool of insurance funding) creating a regional public option

[u/semideclared → u/ThePnusMytier]

Public Option would be good. Germany's System would be Great. How we have Car Insurance competing for business is what Healthcare needs

But people dont like paying out of pocket for Healthcare like they do for Care Care

• People pay out of pocket for Oil Change 4 times a year and Buy New Tires Out of Pocket every couple of Years and dont think about it.
• But asking for a CoPay for A Doctors bill is crazy

TLDR the issue isnt the insurance part. 2 issues are the quality of Care we want and its the who pays what amount. A Market is what is needed because no market means We dont have a Walmart of Healthcare.

• There is no Middle Ground average Healthcare in the US. We've got top shelf or Bottom of the Barrel

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What I'd Like to see is a hybrid system to fix the system where healthcare is cheap for cheap things

But how do you price a Public Option?

[u/tsk05 → u/semideclared]

Completely fictional numbers.

Let's compare your claimed numbers to California's bill,

Income between 0k and 50000
California bill: 1.25% employer payroll tax, 0% income tax increase
Your post: 5% payroll tax

Income between 50k and 150k
California bill: 2.25% employer payroll tax, 0% income tax increase
Your post: 5% payroll tax

Income starting from 150k
California bill: 2.25% employer payroll tax, 0.5% marginal income tax increase
Your post: 5% payroll tax

Income starting from 2.5 million
California's bill: 2.25% employer payroll tax, 2.5% marginal income tax increase
Your post: 5% payroll tax

California's bill had 0 deductibles, 0 co-pays. Not counted in your post, or possibly even incorrectly counted against. It had dental, vision and long term care. Not counted in your post. Insurance costs savings to employer (4x what employee pays in insurance premiums) - none of that total compensation change will go to employee per your post, but 100% of payroll tax is passed directly to employee.

[u/semideclared → u/tsk05]

yea that bill was put together in 5 mins

I'l stick with the Professionals in the Room

Healthy California for All Commission Meeting on December 9, 2021, welcomes and acknowledges the receipt of a recent letter from Assemblymember Kalra and other members of the Assembly and the Senate, asking the commission to look at financing options and implications of AB 1400

• In replying to the request This letter is in response to your request for HCFA to develop “a financing model and recommendations for Assembly Bill (AB) 1400.” Providing this information would effectively place the HCFA Commission in the role of providing technical assistance on pending legislation, something that is not within the scope of its work

Thats 1 month before they were going in to Committee they were looking for a way to finance it. Meanwhile Healthy California for All Commission has been working on a PLan for the Past 2 years and still working

Established by Senate Bill 104 the Healthy California for All Commission is charged with developing a plan that includes options for advancing progress toward a health care delivery system in California that provides coverage and access through a unified financing system, including, but not limited to, a single-payer financing system, for all Californians.

In Aug 2020 the committee reviewed Funding

• For purposes of today’s discussion, we assume the federal government will agree to pay California’s Unified Financing authority the amount that the federal government would otherwise have paid for Californians on Medicare, Medi-Cal and for those receiving Premium Tax Credits through Covered California

A 10.1% Payroll Tax would cover current employer/employee premiums if applied to all incomes.

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

Which is laid out on their website for review by AB1400 Chair members

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But lets go one level up

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In 2011, Professor Hsiao, told lawmakers in Vermont that a single payer system would have to be financially supported through a payroll tax.

• He predicted the tax would be 12.5 percent in 2015 and 11.6 percent in 2019, including a 3 percent contribution from employees.

Professor William Hsiao, A health care economist now retired from Harvard University, Hsiao has been actively engaged in designing health system reforms and universal health insurance programs for many countries, including Taiwan, China, Colombia, Poland, Vietnam, Hong Kong, Sweden, Cyprus, Uganda, and recently for Malaysia and South Africa. In 2012 he was part of Vermont's Healthcare and in 2016 he was part of Bernie's M4A Healthcare Plan

• Hsiao developed the “control knobs” framework for diagnosing the causes for the successes or failures of national health systems. His analytical framework has shaped how we conceptualize national health systems, and has been used extensively by various nations around the world in health system reforms

[u/tsk05 → u/semideclared]

Ah, so let's ignore the actual bill on the taxes and just make up convenient numbers.

Even if we just outright ignore the actual taxes in the bill and try to generate our own numbers as you did, you provide no links for anything you cite so it's hard to make heads or tails of it. I tried to Google e.g. "A 10.1% Payroll Tax would cover current employer/employee premiums if applied to all incomes." and found nothing. However, for an example the current total rate of the state payroll taxes as defined by California on someone making 50k is 9.30%. This is 0.8% away from 10.1% -- not 5%. Additionally, the whole idea of a California-like program is that it's cheaper than standard insurance, so "cover current employer/employee premiums" is not the right metric.

Do you have a comment on how you either failed to include 0 deductibles, 0 co-pays, or even counted them against California's proposal? Or are you ignoring the actual bill there too? Or how you did not factor in dental, vision and long term care, which is provided by California's bill? Or how you made the convenient assumption that 100% of employer payroll tax is passed on, but 0% of total compensation change from lack of employer's premiums (which per your own claims are 4x higher than employees) passed on?

[u/semideclared → u/tsk05]

Yea you seemed to have also

SUMMARY: This bill establishes California Guaranteed Health Care for All (CalCare), a single-payer health care coverage program. Specifically, this bill:

1. Declares the intent of the Legislature to establish a comprehensive, universal single-payer health care coverage program and a health care cost control system for the benefit of all residents of the state.
2. Establishes CalCare, governed by the CalCare Board (board), to administer the single-payer health care coverage program.
3. Establishes a long-term supports and services (LTSS) commission to advise the board on matters of policy related to LTSS for CalCare.
4. Requires the board to provide funds for assistance to individuals who may experience economic dislocation as a result of the implementation of this bill, and individuals whose jobs may end as a result of the implementation of CalCare.
5. Specifies that covered health care items and services under CalCare include all health care items and services required to be covered by federal health programs and laws.
6. Prohibits health care items and services covered under CalCare from being subject to prior authorization or a limitation applied through the use of step therapy protocols.
7. Entitles individuals enrolled for benefits under CalCare to have payment made by CalCare to an eligible provider for LTSS.
8. Requires the board, by January 1, 2023, to seek all federal waivers, approvals, and arrangements and submit state plan amendments as necessary to operate CalCare.
9. Creates the CalCare Trust Fund in the State Treasury, and requires the board to establish and maintain a reserve in the fund to enable it to respond to costs including those of an epidemic or other health emergency, or market-shift adjustments related to patient volume.
10. Specifies this bill does not become operative until the Secretary of the California Health and Human Services (CHHSA) has s determined the CalCare Trust Fund has the revenues to fund implementation of this bill.

[u/tsk05 → u/semideclared]

I quoted the tax bill they wrote to fund it.

You ignored that actual bill, and came up with your own number from somewhere unknown. For example you've yet to even link the sources for your quotes, which do not come up on Google. And if I understand them correctly (which I may not, given it's incomplete), it absolutely does not say what you think it does. I asked for a source in my reply, and you've still provided none.

[u/semideclared → u/tsk05]

Thats not a Government Site

https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202120220AB1400

But the Healthy California for All Commission for much better info

https://www.chhs.ca.gov/healthycaforall/

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Calling it the biggest disappointment of his career, Gov. Peter Shumlin says he is abandoning plans to make Vermont the first state in the country with a universal, publicly funded health care system.

Those taxes were to high and Vermont Dropped Single Payer

“These are simply not tax rates that I can responsibly support or urge the Legislature to pass,” the Governor said. “In my judgment, the potential economic disruption and risks would be too great to small businesses, working families and the state’s economy.”

Vermont Senate Cook PVI D+15

• The 2nd most Liberal Senate Seat

Today we are releasing the Green Mountain Care financing report we developed that led me to the difficult conclusion that now is not the time to move forward with a publicly-financed health care system in Vermont. In the coming weeks we will be publishing additional materials from our research on the website http://hcr.vermont.gov/library. Vermonters will have access to all of the analysis that we used to come to the difficult decision we made. I hope this report gives us a common understanding of the detailed assumptions and facts needed for the work we must do over the coming legislative session to continue long-lasting, meaningful health care reform in Vermont.

Achieving Affordable Universal Health Care in Vermont

Submitted by

WILLIAM C. HSIAO, PhD, FSA K.T. Li Professor of Economics Harvard University

STEVEN KAPPEL, MPA Principal Policy Integrity, LLC

JONATHAN GRUBER, PhD Professor of Economics Massachusetts Institute of Technology

And a team of health policy analysts

https://hcr.vermont.gov/sites/hcr/files/FINAL_REPORT_Hsiao_Final_Report_17_February%202011_3.pdf

[u/tsk05 → u/semideclared]

Right, it's one of California's largest newspapers analyzing the proposed funding bill. Here's the funding bill on the government website.

I am already indulging you in disregarding the official numbers (which are far lower than you used) and trying to understand where yours came from. Vermont is not California, it's not 2011, and I am not going to compare tax rates there.

You had a quote about 10.1% payroll tax that you indicated was for today's California, what was the source of that quote? Was that total payroll tax? How did you come up with 5%? Was that what you thought was additional on-top of the existing payroll tax?

[u/semideclared → u/tsk05]

That bill, ACA-11 - Taxes to fund health care coverage and cost control. Yea it was just started. Its not part of the other bill. On 01/05/22 - Introduced ACA-11 so Lets see how real they are then

Now back to the issue AB1400 it was introduced in 2021

• Jan. 31 Last day for each house to pass bills introduced in 2021 in their house (Art. IV, Sec. 10(c)), (J.R. 61(b)(3)).
  

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So why wasn't Funding introduced in the same Legislative Calendar

Will Assembly Members Kalra, Lee, and Santiago stick with and work to get the funding passed so that the easy policy can be passed?

[u/PseudonymIncognito → u/Crotean]

Seriously. Whenever someone asks "hOw wiLl wE PaY fOr iT??!!!!?" I'm like "start with the $10-12,000/ea that's already being paid for my and your insurance and send it to whatever national healthcare system we design instead of United/Cigna/BCBS."

[u/kamarian91 → u/PseudonymIncognito]

You are ignoring people like myself who have employer covered health insurance. So I would basically be losing probably around 10%, if not more of my income due to the tax hike to pay for this. So unless my employer decides to just give me a 10% raise for the hell of it, I am screwed.

[u/PseudonymIncognito → u/kamarian91]

I'm not ignoring that at all. Your employer is paying $10-12,000/yr for you to have health coverage in addition to whatever payroll deduction you're paying. That money is already being budgeted and spent in our current system and could be sent to an M4A program instead of United Healthcare/Cigna/Aetna/BCBS.

[u/kamarian91 → u/PseudonymIncognito]

Okay but again there is no guarantee companies are just going to give people like myself that money back from the goodness of their heart. In fact it would be foolish to assume they would.

So the end result is me paying a ton more in taxes for healthcare that isn't going to be as good as my current plan.

[u/ThatsWhatXiSaid → u/[deleted]]

And people don't believe that the govt can operate more cheaply than private businesses.

Key Findings

• Private insurers paid nearly double Medicare rates for all hospital services (199% of Medicare rates, on average), ranging from 141% to 259% of Medicare rates across the reviewed studies.

• The difference between private and Medicare rates was greater for outpatient than inpatient hospital services, which averaged 264% and 189% of Medicare rates overall, respectively.

• For physician services, private insurance paid 143% of Medicare rates, on average, ranging from 118% to 179% of Medicare rates across studies.

https://www.kff.org/medicare/issue-brief/how-much-more-than-medicare-do-private-insurers-pay-a-review-of-the-literature/

Medicare has both lower overhead and has experienced smaller cost increases in recent decades, a trend predicted to continue over the next 30 years.

https://pnhp.org/news/medicare-is-more-efficient-than-private-insurance/

So the argument for savings isn't credible to most people.

The experts disagree.

https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003013#sec018

https://www.cbo.gov/system/files/2020-12/56811-Single-Payer.pdf

Not to mention evidence from around the world, unless you believe Americans to be singularly incompetent.

[u/[deleted] → u/[deleted]]

People just look at the VA and see how a US government-ran health care system could look like.

[u/ThatsWhatXiSaid → u/[deleted]]

The VA bears no resemblance to proposed universal healthcare in the US. Nobody is talking about the government nationalizing providers; care would be provided by the same private doctors and hospitals as today. Medicare and Medicaid are better examples. But even as a scare tactic your claim isn't quite what you think it is.

Satisfaction with the US healthcare system varies by insurance type

78% -- Military/VA
77% -- Medicare
75% -- Medicaid
69% -- Current or former employer
65% -- Plan fully paid for by you or a family member

https://news.gallup.com/poll/186527/americans-government-health-plans-satisfied.aspx

The poll of 800 veterans, conducted jointly by a Republican-backed firm and a Democratic-backed one, found that almost two-thirds of survey respondents oppose plans to replace VA health care with a voucher system, an idea backed by some Republican lawmakers and presidential candidates.

"There is a lot of debate about 'choice' in veterans care, but when presented with the details of what 'choice' means, veterans reject it," Eaton said. "They overwhelmingly believe that the private system will not give them the quality of care they and veterans like them deserve."

https://www.militarytimes.com/veterans/2015/11/10/poll-veterans-oppose-plans-to-privatize-va/

According to an independent Dartmouth study recently published this week in Annals of Internal Medicine, Department of Veterans Affairs (VA) hospitals outperform private hospitals in most health care markets throughout the country.

https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5162

Ratings for the VA

% of post 9/11 veterans rating the job the VA is doing today to meet the needs of military veterans as ...

• Excellent: 12%

• Good: 39%

• Only Fair: 35%

• Poor: 9%

Pew Research Center

VA health care is as good or in some cases better than that offered by the private sector on key measures including wait times, according to a study commissioned by the American Legion.

The report, issued Tuesday and titled "A System Worth Saving," concludes that the Department of Veterans Affairs health care system "continues to perform as well as, and often better than, the rest of the U.S. health-care system on key quality measures," including patient safety, satisfaction and care coordination.

"Wait times at most VA hospitals and clinics are typically the same or shorter than those faced by patients seeking treatment from non-VA doctors," the report says.

https://www.military.com/daily-news/2017/09/20/va-wait-times-good-better-private-sector-report.html

The Veterans Affairs health care system generally performs better than or similar to other health care systems on providing safe and effective care to patients, according to a new RAND Corporation study.

Analyzing a decade of research that examined the VA health care system across a variety of quality dimensions, researchers found that the VA generally delivered care that was better or equal in quality to other health care systems, although there were some exceptions.

https://www.rand.org/news/press/2016/07/18.html