[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. ___________________________________________________________________ (page generated 2022-05-09 23:00 UTC)