The Core

>> would oppose the idea if it meant many Americans would have to pay higher taxes

Here in Canada we pay higher taxes because of our Medicare but we escape the mess of insurance payments that our US friends face. Our net costs are less.

Our average life expectancy is two years longer than our US counterparts, yet medical costs are a significantly lower percentage of our GDP than in the US (something like 12% vs 18%).

Single payer has a lot to recommend it.

20 percent flipped and said they would oppose the idea if it meant many Americans would have to pay higher taxes.

Oh my people.

For the 20% who shift, it's as if we had a 100% toll highway system and they were asked, would you support a toll-free highway system? And they answer yes. Then get told that a highway still costs money, so they would have to pay taxes, then said no.

Don't get me wrong. I can see saying no. Certainly a person who doesn't drive might have trouble seeing the benefit (though the benefit is there, since the person who doesn't drive is certainly getting deliveries). But the flipflop when you realize costs don't suddenly vanish is the part that astounds me.

>Single payer has a lot to recommend it

I agree, sorta. In the long run, according to Brits here, single payer tends to crap out... stuck between two worlds.

As far as I can see, every system in the world is running into issues with cost containment and will continue to do so. I recently saw an interview with a guy who was high up in the Nixon administration and had something to do with health insurance under Nixon. He was commenting on the current fracas over ACA/AHCA and said that he saw no way to deal with healthcare in the US long-term other than single-payer. He personally said he didn't like single-payer, but that whatever solution he liked (he didn't go into it much) would never be politically viable (which is saying something if he thinks it's got less of a chance than single-payer).

But no matter what, we have to get costs down and that means among other things fewer service delivered by MDs. For several years now, self-learning diagnostic systems have had better track records than MDs, but both doctors and patients shy away from them. But generally speaking, diagnosis can be done *better* by someone with a smart system and a two-year training. That saves not only all the MD time on diagnosis, but saves all the time treating the wrong condition.

The current US system incentivizes doctors to be wrong. If a doctor is wrong, he gets repeat business. It's one of the few fields where that's true. We just had someone at our house who runs the wellness program for a hospital and she said there was this "Wait? What?" moment a few years into it when they realized it was working and patients weren't coming back and that was bad for revenue (anecdotal of course).

All of which gets me to this

Californians would not have any premiums, copays, or deductibles

This is bad. One of the problems in healthcare is that consumers have no clue how much things cost. There is a name for a market like this, but I can't recall it... It's similar to the college textbook market where the person making the buying decision (the professor) never pays for the product and the end user is commonly subsidized (parents or govt loans).

I would support a system with copays and deductibles based on income. Seriously, a $1000 deductible is not going to change my habits (not counting vision, I've only had 4 doctor visits in 20 years, two for an injured finger tendon and two for physicals).

I get that people on limited income will put off care if they have copays, and the long-term cost goes up. But frankly, the large number of people who are getting tested for every imaginable food and chemical sensitivity, the large number of people who go to the doc to seek antibiotics for their cold (which is viral people!) and so forth should have some skin in the game.

So... it turns out this will require $200b extra, and will shave $100b to $150b that get deducted from wages currently (as per the article). So there's $100b unaccounted for.

Let's say the median Californian spends $500/yr out of pocket - it has to be somewhere north of that because we average more than that and all we do is go to the dentist and the eye doctor. So with 40m people, that's $20b right there.

So we're down to $80-$130b shortfall.

There are 19 million workers in CA - https://www.bls.gov/eag/eag.ca.htm

Taking the middle: $105b/19m = $5500.

So that's $5500 extra if you're currently covered by insurance on average.

Now it gets too complicated for my brain though, because a progressive tax system means that people at the bottom end won't pay close to $5500/year.

And then there's the issue that "free" healthcare will increase consumption of services. Is the infrastructure there to deliver?

Then there are some obvious benefits
 - preventative care to avoid hugely expensive emergency care (I bet ER admissions would go way down).
 - preventative dental care, which has become a "rich" person's thing, as widely reported recently.
 - address income inequality - as it is now, healthcare is shared evenly. At my company, the lowest wage earner and the CEO have the same contribution, and some analyses I've seen says that rising health insurance premiums account for almost all of the missing wage growth in the "anemic recovery" since 2008.

At then end of all that, I feel like I need a lot more info to decide whether this is actually good or bad.

To put it in perspective I've had to pay as much as $1.6k/month to insure my family so $5500/worker sounds like a pretty good deal to me.

<added>
Meanwhile, the new US budget proposal has surfaced.

The biggest savings would come from cuts to the Medicaid healthcare program... ...more than $800 billion

...and more than $192 billion from food stamps.

Ouch! That's going to leave a mark.

To put it in perspective I've had to pay as much as $1.6k/month to insure my family so $5500/worker sounds like a pretty good deal to me.

The 1.6K is already factored in. That's how you save the first $100b. The *second* $100b is the part that you don't save by cutting premiums. So the relevant number is your out of pocket expenses.

>>Advances in AI

Watson. But non-AI systems were already outperforming MDs over a decade ago. My brother was in the industry and there was already ample evidence, but the cultural factors were the holdup. Consider how people are leery of self-driving cars, even when they outperform human drivers and add 100%. And doctors generally don't like it.

There are two models by which doctors get paid in the US
 - fee for service, which drives cost up because the incentives are to offer more services, needed or not.
 - fee per patient (doctors at HMOs), which drives quality down because the incentive is to push people through as fast as possible.

Advances in AI will help, but you have to get people using them. And part of that would be paying doctors salaries with perhaps some incentives based on outcomes. This is one of the more successful parts of Obamacare that people don't talk about much. Providers could opt in to be paid a flat fee to treat a given problem. The incentive then is to get the treatment right the first time and avoid readmissions. I read one article that said that readmissions in hospitals that opted in were down. Basically, that system incentivizes good care, not extra care or insufficient care.

From the article:

Of that, $200 billion of existing federal, state and local funds could be repurposed to go toward the single-payer system.

The $200/billion in savings is from the existing state run health plans (Covered California, Medical, etc.), not private insurance.

The state would have to come up with another $200 billion from taxes, but that would be offset by what people are currently paying the insurance companies.  Doing quick math, if there are 19 million workers and they (and their employers) pay an average of $12 thousand a year then that's over $200 billion right there.  So, it looks to basically be a wash, with the benefit of everybody having insurance and getting preventative care.

We LEFT California, in part, because of issues like this.

It makes me SAD to look back.

We still have family there.

PS: I prefer to purchase insurance for my family from a fiscally sound entity. Whatever that is...