[dalke]

When I had a small business in the US, my biggest concern was figuring out medical insurance and retirement. Since I had no clue one what to choose from the myriad of options.

I wanted more government control - single payer health care and decent Social Security coverage. I didn't feel overtaxed either.

I still feel that unions are far more over-regulated than businesses. I think many of the employee laws the article mentions are in place because collective bargaining has been so nerfed that the only remedy to bad but common management abuses (eg, wage theft) is through the legal system.

[beached_whale]

I think of a single payer system as infrastructure like roads, electrical supply, water... It collectively takes the risk from the individual and provides for everyone. A business no long gets distracted with pension, drug, medical... and focuses on the business of making money. They pay tax and that is it.

In an ideal world.

[crazy1van]

>A business no long gets distracted with pension, drug, medical

Unless that business was in the pension, drug, or medical industries.

My point is that it's not super clear where to draw the line between common public services and businesses, and people's perspective is usually determined by the nature of their own business.

For example, provide gov't healthcare and pensions so my smartphone company can focus on making great devices instead of worrying about health care.

Or... provide gov't smartphones so my social media app company can focus on making great apps rather than worrying about what mobile OS to support.

Or... provide gov't social media apps so my independent media company can focus on generating content rather than worrying about distributing it across many social media platforms.

[dalke]

There are still companies involved with "roads, electrical supply, water", even when they are part of the public infrastructure. It's not like there are no drug or medical companies in Switzerland.

The evidence doesn't need to be "super clear." The numbers are pretty solid that universal healthcare is more efficient than the current system the US has. That is, the US government spending alone, on a per capita and GDP basis, is higher than the combined public+private spending in most countries with universal health care. Yet the public+private funding in the US doesn't result in a higher quality of health care, by most measures.

Even sticking to the US, we can get an idea from Medicare and the VA system of the advantages to single payer systems.

Those comparison numbers don't exist for the proposals you mentioned, and there is no reason or experience to suggest they make sense in the current market. (But, consider France's Minitel in the 1980s, when it did make sense.)

Also, the failure costs in health care are much higher than the failure costs in choosing the wrong mobile OS. The worst case for the former is an nation-wide epidemic. The worst case for your company is ... you run out of money and need to get a job.

[jomamaxx]

Health Care is not like building roads.

I live in Quebec, Canada and the healthcare here is among the worst in the civilized world.

Also - it's illegal to pay a doctor to fix you. Canada is the only place in the world where it's illegal to pay someone to cure you of something. It's basically communist.

The American system is untenable, but 'single payer' is not the solution.

Successful countries that do it are tiny. Sweden is smaller than Los Angeles. Swtizerland does it at the cantonal level, which on average is 800 000 citizens. Can you imagine your entire hospital and insurance system being in blocks of 800 000?

Maybe at the state level, subsidies, regulating drug prices etc. etc. - but full-on national level 'single payer' would be a huge disaster, beyond contemplation.

Also in many single payer systems - the guy who snuck across the border illegally gets the exact same healthcare as you, working professional, paid a million in taxes, dutiful citizen etc..

I think there should be coverage for everyone, but single-payer is not the path.

[dalke]

Health care also isn't like writing software. I know how to write software. I don't know how to select health care plans, and I when I had my own US company I was always afraid that I had made the wrong choice.

> "Can you imagine your entire hospital and insurance system being in blocks of 800 000"

I now live in Sweden, so I'm not unfamiliar with how single payer works in a country of 9 million people. Do note that it's not so isolated as you think. If I were to travel to France, and fall ill, I am entitled to any medical treatment that a resident would receive. This includes Switzerland, so your statement isn't quite a match to how the system works.

And let me say that it's a big relief to not worry about those details anymore. With our first kid on the way, I didn't have to wonder if my insurance would cover everything, or if I was feeding into the cost machine that has caused the price of giving birth to triple over the last 20 years in the US.

> "Successful countries that do it are tiny"

icebraining pointed out the 63 million people living in the UK with its NHS.

Even in the US, there are about 9 million people in the VA system and 55 million people in the Medicare system. Is there some fundamental reason which explains why Medicare cannot scale by a factor of 6?

> "the guy who snuck across the border illegally gets the exact same healthcare as you"

First, in the US everyone, no matter their immigration status, has the right to emergency care. See http://www.medscape.com/viewarticle/590328 for how the ethics are clear. So you end up with pregnant women coming to ER to give birth, which is expensive. And you have people coming to ER for things that could have been handled at a clinic more cheaply, and before any complications might have come up.

To make things more complicated, how does this hypothetical border crosser live in the US without a job? Because if he had a job enough to live on, then either the US employer is paying under the table, or he has a falsely acquired SSN and is paying into Medicare, even if he can't use it. The same works for universal healthcare - the money comes from payroll tax/automatic salary deductions, so even if someone snuck across the border, as long as they have a job they are paying for healthcare.

Second, people visiting (say) France from a country outside Europe are not covered under the French system. They are supposed to pay. Indeed, they do pay. Medical tourism is a thing. People will travel to France for treatment, and they pay for the treatment. It is not free to all comers. When my then-girlfriend visited me in Sweden for a couple of weeks, she needed an emergency root canal. She had to pay, and she did, even though she isn't a dutiful Swedish citizen.

But sure, there are people who are in the country but aren't eligible for health care and can't afford to pay or refuse to pay. There are two options 1) treat them, 2) don't treat them and wait until they appear in the ER once the problem gets more serious. (Option 3 is let them die, but I'm not inhumane enough to want that.)

Which is why the following happened in Spain. "Under a reform that came into place in September 2012, foreigners without residency papers lost their national health cards which allowed them free treatment in local public health clinics." Then in 2015, "Spain's conservative government said ... it would restore free healthcare for illegal immigrants, overturning a controversial decision taken three years ago." - https://www.thelocal.es/20150331/spain-to-restore-free-healt...

And they did it to take the load off of expensive ER care, which even the non-single-payer US does.

[jomamaxx]

"Do note that it's not so isolated as you think. If I were to travel to France, and fall ill, I am entitled to any medical treatment that a resident would receive. This includes Switzerland, so your statement isn't quite a match to how the system works."

+ Yes - it is. Your system is absolutely isolated from the French system. The fact you can get coverage is no different from the fact I can get coverage in another province. There is absolutely no operational relationship between French and Swedish healthcare systems.

"Even in the US, there are about 9 million people in the VA system and 55 million people in the Medicare system. Is there some fundamental reason which explains why Medicare cannot scale by a factor of 6?"

Ask yourself the question: would you want a 'EU' level healthcare system - where Greeks, Swedes and Bulgarian were managed by the same entity? Do you grasp why that would not work? Greece is a completely dysfunctional country. How do you think it would fare under the 'same system'? Would Doctors in Greece be granted retirement at age 55, but Swedish Doctors not until 65? Under the same pay? It would never work.

+ It doesn't matter that everyone is entitled to some kind of 'emergency service' - and frankly - I'm not against that. But what if you were to put people who illegally into the country 'last week' - ahead of American citizens who required 'knee surgery' and because of this - American citizens who wanted (and paid for) knee surgery, went from waiting on average 2 weeks, to 18 months. Is this fair, or even moral? It's absurd. If people want to pay for healthcare, they can pay for the service to have it in two weeks.

The question of 'how much medical coverage we give to illegal citizens' is really another question entirely.

[dalke]

You argument is that single payer only works in countries with a small population. How come it manages to work with the British NHS and the US Medicare? Why can't those systems scale up by a factor of 10 to work for the entire US population?

Or, let's agree that it only works for a UK-sized population of 80 million or smaller. That's fine. Even California only has a population of 40 million. Let each state run its own medical system, and some of the smaller states can form a interstate compact to share costs.

I had no idea what you are talking about with knee surgery. I believe that a decade ago the queue for non-emergency knee replacement surgery in the UK could be 18 months, but it's 18 weeks now. https://www.theguardian.com/society/2015/jul/24/nhs-waiting-...

Nor was delay caused by non-UK people getting priority. A non-resident does not somehow have priority over all citizens. It's the same queue. Unless coincidentally every single non-resident needed immediate knee surgery, while the resident need wasn't so critical, what you describe (17 months added to wait time because non-emergency health care is extended to people not in the health system) cannot happen.

FWIW, in the 1980s, "The median waiting time for an initial consultation was two weeks in the United States and four weeks in Ontario ... The median waiting time for knee replacement from the time surgery was planned was three weeks in the United States and eight weeks in Ontario. ... Overall satisfaction with surgery (85.3 percent of U.S. respondents and 83.5 percent of Ontario respondents were “very or somewhat satisfied”) was not associated with the duration of the wait for surgery" - http://www.nejm.org/doi/full/10.1056/NEJM199410203311607#t=a...

Sure, that was the 1980s, but it shows that single payer even in Canada doesn't intrinsically end up with 18 months of wait time for knee replacement surgery.

Those comparison numbers are biased. They only include people who had knee surgery. In the US, the uninsured, or those who switch jobs only to find out that it's a "preexisting condition" under their new plan, may not be able to afford it. (And yes, the fear of losing coverage keeps some people working at otherwise horrible jobs.)

Their years of extra pain aren't included in the average or maximum queue times.

> "If people want to pay for healthcare, they can pay for the service to have it in two weeks."

Sure. But single payer doesn't require that there cannot be private doctors as well. The UK has private health care in addition to single payer universal health care. Here's a price list for private knee replacement surgery in the UK: http://www.privatehealth.co.uk/conditions-and-treatments/kne...

I already mentioned health tourism where people go to France for surgery that is cheaper than the US. Back when the wait time was long in the UK, the NHS even sent people to France for treatment - http://news.bbc.co.uk/2/hi/health/1510522.stm . Here's a price list for private knee replacement surgery in France: http://www.treatmentabroad.com/surgery-abroad/france/surgery... .

As that BBC article points out, "The move follows a European court ruling which broadens the circumstances under which countries can carry out reciprocal treatment. ... Mr Milburn's statement follows a ruling by the European Court of Justice (ECJ) that patients facing "undue delay" in their home countries could seek treatment in other EU states."

Tell me again how the other medical systems in EU are "absolutely isolated from the French system"?

[icebraining]

Not a word about the UK's NHS?

[jomamaxx]

You can vote me down if you want, but I live in a system where I cannot get a doctor. And it's illegal to pay for one. I' forced by the government, to use local clinics where they don't have my records, I don't have a relationship with the doctor, they can't make longer term prognosis, and frankly, the care is sub-par.

I once had an ailment that was difficult to diagnose, the doctors at the clinics, used to seeing people for coughs and colds could give a shit. I ended up having to pay a few grand for an American entity operating barely within the bounds of legality in Canada (the Cleveland Clinic). I can assure you that it's a pretty desperate feeling when you are locked out of the system.

Notre Dame Hospital in Montreal is lined with people in beds in the hallways, broken chairs, broken, leaking water fountains in the waiting room, broken / discarded beds in the waiting room - I thought I was in Cuba. The doctor was actually nice but the facilities were crazy. A well run McDonald's has more visible operating efficiency.

It's far from optimal.

[dalke]

I think you might be downvoted because your complaint is not an intrinsic problem with single payer systems, nor is it common in those systems.

I could turn around and point to poor people from rural communities in the US, who can't afford healthcare, and depend on free mobile clinics like http://abcnews.go.com/Health/mobile-free-clinic-brings-healt... .

BTW, Cuba appears to have a significantly better system than what you describe.

Cuba also trains doctors for other countries, including people from the US. Medical training in the US is so expensive that people who want to be doctors for the poor can't afford the loans. See http://www.pbs.org/newshour/rundown/cuba-offers-poor-med-stu... .

[jomamaxx]

"uba appears to have a significantly better system than what you describe."

Cuba has no money. They pay their doctors roughly $10/week.

Do you think Cuba can afford all of the drugs, diagnostic equipment, software and services that are required to make a highly functional modern Medical system?

Of course not. I made a reference to Cuba out of sarcasm - there is no defending the Cuban system, other than to say that they can provide adequate 'very basic coverage' to it's citizens, which is good.

They pay their doctors literally less than the cost of many common and important therapeutic drugs. It's an economic non-sequitur.

[dalke]

For your "sarcastic" comment, you happened to pick one of the developing countries known for doing well with limited resources, with child mortality and longevity rates comparable to the US.

A country which, btw, is also promoting medical tourism. Which includes Canadians going there - http://www.nytimes.com/2015/02/18/world/americas/americans-m... . Perhaps you could go there for treatment?

Though from http://bmchealthservres.biomedcentral.com/articles/10.1186/1... it looks like more Canadians go to India. (The US isn't on the list because Canadians don't think of that as international travel.)

[DanBC]

You'veused your limited canadian experience to say that single payer everywhere is a terrible idea.

You're using some things which are peculiar to the canadian system (particularly the banning of private medicine) to say why single payer can't work anywhere, even though most other places allow private healthcare.

[jomamaxx]

My experience is not unique, it's common.

'Single payer wherein you cannot buy private services' is basically unique to Canada, and is fundamentally part of the reason that the quality of care and services in Canada is so bad.

My fellow Canadians are smug and righteous about their system, thinking that it's superior to the American system.

Anti-American bigotry is frankly rampant in Canada.

I lived in the US (and abroad) for many years, while most of my peers have never spent more than a few weeks in the US - and their understanding of the system is nill, and comes from the highly biased and borderline propaganda they get from our 'State Controlled National News' entity - the CBC. I generally like the CBC, but they also support national programs, and most of their staff don't have the relevant experience or competence to make any assessment.

My position on healthcare is a lot more nuanced.

Canadians are almost religious about their healthcare system, they have little grasp of how things work elsewhere, and little awareness of how poorly their system fares against other system.

[NotSammyHagar]

Yes, thank you for posting this. It's exactly the case that if one were to start a small company, the more govt services that automatically take care of things like ins and retirement, the easier it is to focus on your business.

[orangecat]

This seems like a false dilemma. Housing, food, clothing, and most other things are not directly provided by either employers or governments, and yet people are able to acquire them.

[dalke]

I started learning about housing, food, and clothing from my parents, when I was a toddler. They taught the basics, including how to cook, how to buy groceries, how to maintain a house, etc.. I had over a decade of practice under their watchful eyes before doing it on my own.

Then in school we learned more about food during health class. Those who wanted to learn more could take home economics. Also, many people purchased magazines to help understand and select clothing styles, participated in discussions on the topic, and spent a lot of time at stores evaluating the different options (i.e, "hanging out at the mall").

Even for housing, I did it in steps, with college dorm, then shared apartments, to shared houses, to my own apartment, to my own house.

By comparison, when I started my company, I had no corresponding practice or experience in selecting health care or retirement options.

Just like I had no practice in reading NDAs and consulting contracts, or setting up a company. But those are remarkably stable. A NoLo book on consulting and the advice of a friend who started a company a couple of years previous was enough. Then hire a CPA who has a legal obligation to work in my best interests.

An insurance agent does not have the same obligation. I also don't have the experience to judge between the offerings from the different companies, nor experience in the local hospitals or clinics to know who is in which system or what I should be watching out for.

That's straight 'paradox of choice', making it all the more difficult to figure out what to do.

It didn't help that every few months I would get a message that the health insurance rates were increasing, making my wonder if I had made a mistake and was being screwed over by the insurance company, who knows that most small business owners really don't want to deal with re-evaluating the insurance market all the time.