[df3]

A well-executed single-payer system would make California even more attractive for entrepreneurship and increase labor mobility for everyone. Life would be much easier if we could start companies or switch jobs without worrying about healthcare.

[neltnerb]

Completely agree. The trick is making sure it's well-executed so that other states can use it as a template. Once one state proves that single-payer can be done well, I suspect it will cascade inevitably.

With 100% seriousness, if the ACA is repealed I will likely be choosing between Massachusetts (where Romneycare would hopefully take priority again) or another country. It's too risky to do otherwise.

My extended and immediate family members have too many horror stories about being denied coverage or it being prohibitively expensive. Like a cousin who had to choose working over being a stay-at-home mom to take care of her kids, since her husband's policy as an entrepreneur wouldn't cover her. She didn't even have any ongoing health problems, just a technical pre-existing condition.

I am unwilling to be stuck in a job or forced to accept unreasonable compensation or a nasty work environment because I have to have health coverage. Which is a decision too many in my family have been forced to make. Many family members (including myself) have far worse chronic illnesses, so it's utterly involuntary -- work or die. And thankfully I have a choice in where to live by virtue of my education and credentials.

I have been blessed so far to not have to deal with it because I've only lived in MA as an adult prior to Obamacare -- where Romneycare was in place by the time I finished undergrad. But I've heard enough first hand accounts and seen the suffering that kind of horrible choice creates. And the absolutely perverse incentives it puts onto the job market, and onto individuals. Health care is not a voluntary market, and treating it like one is bonkers.

Now I'm in California. I seriously doubt I will be able to stay without a guarantee that I can manage medical expenses, and I'm definitively privileged economically compared to the majority of the US population.

[zaroth]

California had guaranteed issue before the ACA. Any small business with at least 2 employees could get it. Premiums were reasonable as the "rating adjustment factor" was capped on these plans. A one time 6 month waiting period on pre-existing conditions is waived if you have prior credible coverage without more than a 62 day gap in coverage.

For example, a husband and wife working together in a sole proprietorship, would qualify.

I'm not sure the current state since ACA passed, but I depended on CA guaranteed issue myself for several years before ACA and it provided access to high quality expensive insurance (~$500 / person / month) with unlimited annual benefits, as well as somewhat cheaper HMO plans (~$350-400 / person / month).

Google 'AB 1672'.

[neltnerb]

Thanks, very helpful to know. Most of my family is in Ohio, and I'm a recent transplant to California.

This appears to be the updated version of AB 1672, which itself ended in 2013:

http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?...

I'm not remotely capable of parsing all the stuff in there, but it does make me wonder what happens when a State passes a bill to bring itself into compliance with a Federal law and then the Federal law is repealed. I assume it's not automatic that the State bill ceases to function.

Is this even more of an uncertainty-laden mess than I thought? Will dozens of states find that changes to the ACA is interacting in crazy ways with state laws? Somehow I am guessing that we won't find out until it happens.

[andrei_says_]

> ... stuck in a job or forced to accept unreasonable compensation or a nasty work environment because I have to have health coverage.

Which is what makes this a huge political issue and an incredible leverage point.

I wish we could unite and end the use of healthcare coverage / availability to enslave workers ("enslave" being used loosely for the ones Who are as pedantic as I sometimes am).

[erichocean]

> It's too risky to do otherwise.

Uh, you could just buy insurance yourself. It's not like no-ones covered unless the State writes the check. smh

[genericpseudo]

This is the point where America discovers European liberal political theory and praxis! This is one of their key points; universal healthcare is a hard-L liberal position because only the state can insure certain classes of catastrophic risk, and by doing so you increase individual freedom of action.

(European liberalism is clearly culturally distinct from social democratic thought; where it comes to the same positions it's typically by other means – not that there's anything wrong with social democracy or democratic Socialism, for that matter.)

A good starting point would be, at pan-Europe level, the ALDE; https://en.wikipedia.org/wiki/Alliance_of_Liberals_and_Democ.... National-level parties you might have heard of are the Liberal Democrats (UK) and Democraten 66 (Netherlands).

[davidw]

Very much agree. I wrote this about single payer, entrepreneurship and my time in Italy:

https://journal.dedasys.com/2017/02/22/entrepreneurship-and-...

[mmanfrin]

I managed to crash my bike in to a car in Italy; I remember the process of going to a doctor (which happened to be the closest door on the sidewalk where I hobbled over to) and having them send me to a hospital. I got looked at, xrayed, and given a diagnosis without having to even talk about money or anything beyond a 4-line form for my information.

Single-payer is wonderful, and I believe an absolute necessity as we march towards a future of automation and enormous economic inequality.

[df3]

Thanks for sharing! I also lived in Berlin for four years and was impressed with how easy healthcare was.

[TheOsiris]

I don't think anyone disagrees that single payer requires higher taxes than we currently pay. so given that, you're trying to tell me that a state with the highest taxes (much much higher than #2) in the nation, with the lowest housing affordability will attract more entrepreneurs than before?

why? because the young and invincible will be choose cheaper healthcare over being able to live comfortably? I highly doubt it. this has nothing to do with whether or not single payer is a good idea. I just did the idea that people will choose CA over cheaper states just for that reason

[ihaveajob]

I can't speak for everyone else, but the two reasons that were holding me back as an employee of a large corporation instead of starting my own company were employer-provided healthcare and visa restrictions at the moment. This measure would have eliminated one of those major constraints.

[dariopy]

CA #1? What are you talking about? The state with the highest tax burden is NY. CA doesn't even make it to the top 10.

https://wallethub.com/edu/states-with-highest-lowest-tax-bur...

[piedpiper_]

California has the highest income tax rate in the nation which directly impacts entrepreneurs starting a business (if they are successful and create wealth). Why would any sane person want to shave off an extra 13 cents for every dollar they make when they're already losing 40 cents per dollar from the federal government? This is why many entrepreneurs are choosing states with low or no income tax and leaving CA and their hyper-liberal state gov behind.

[http://www.cpapracticeadvisor.com/news/12281147/irs-income-t...]

[FullMtlAlcoholc]

> Why would any sane person want to shave off an extra 13 cents for every dollar they make when they're already losing 40 cents per dollar from the federal government?

The beautiful weather, the beautiful people, the amazing weather, the topographical diversity that allows you to surf and snowboard on the same day, the amazing hikes, the national parks, the ability to bike to work year round. Silicon Valley "manages" to attract a lot of entrepreneurs, but maybe you think they're all insance?

You could eliminate all taxes and I still wouldn't choose to live in Texas or Florida. You could increase my salary 10x and I wouldn't move to Nebraska, the Dakotas, Arkansas, Oklahoma, Kansas, or Iowa. Then again, you could hire for remote positions if you need devs.

[neltnerb]

I think you added the wrong link, which I had assumed was a reference to your claim that "many entrepreneurs are choosing states with low or no income tax". It appears to just be a link to Federal tax brackets. Do you have something to actually back up that claim?

I ask because it's very counterintuitive -- entrepreneurs are pretty much never showing much personal income for years since it's all in equity. And by the time they are making that much personal income, they're presumably just as well off as a normal employee with that income.

The only things I ever hear about that incentivize startups to move somewhere are the (a) ecosystem of support (b) availability of low cost facilities and (c) state tax credits or grant award opportunities, such as matching grants with federal SBIR grants.

I have literally never heard an entrepreneur suggest moving to a new state because of personal income taxes. If personal income is high enough that it's a problem, they're probably well enough off that they can afford it regardless of whether they're an entrepreneur or not.

Unless maybe you're talking about how progressive taxes in general do a bad job at the whole variable income thing. I hear lots of complaints about that with regard to personal income taxes from friends who are more contractor/consulting focused. But that's also not a California thing.

[digitalzombie]

Your link doesn't prove anything it's just a federal tax.

The other reply posted a link and California does not have the highest income tax rate, it's 4th.

So from the get go your premise is false.

Also liberal or not you're stating an opinion of why hypothetical companies should do this and that, all the while we still have Silicon Valley and Hollywood in California. So in the face of reality you have not yet successfully prove or convincingly argue that high tax will drive away companies.

[SamPhillips]

You mean, other than the insane people at: Apple, Google, Facebook, Twitter, Oracle, HP, Uber... Clearly some successful entrepreneurs find that the 13 cents to still be worth it to have access to the talent and ecosystem. Perhaps there is something about liberal policies that encourages more successful entrepreneurism. Massachusetts, with best-in-the-nation insurance coverage thanks to RomneyCare also as an outsized tech scene.

[nickv]

I remember these arguments made when Jerry Brown first proposed the newer upper income tax bands in 2009.

Considering, for a very long time, California's taxes have been the highest in the country (to be fair, definitely not "much much higher" than NYC,) last I checked it was adding jobs at a higher percentage rate than any other state.

Do you really think there's been an entrepreneur exodus from the Bay Area and LA since 2009?

[deepnotderp]

But don't you know? He learned in econ 101 that high tax rates are bad! Why he's Basically a Nobel prize winning economist!

[DrScump]

  I don't think anyone disagrees that single payer requires higher taxes than we currently pay

I disagree, in the sense that I don't take that as a given. Remember, all of the current inefficiencies in and profits for the carriers go away and are instead fed directly into the system of care.

The first problem is, how could the government simply take over? Eminent Domain? Constitutional amendment?

[xienze]

> I disagree, in the sense that I don't take that as a given.

Well it depends who you're talking to. If you're poor, the impact on your income tax will be nothing. If you're like me, i.e. you have a fantastic employer plan with an annual premium amounting to ~4% of your annual salary, then you can bet your ass you'll be paying more in taxes and getting a worse product to boot.

[SilasX]

True, but the parent was speaking specifically to taxes alone, while your reply is referring to a different claim, about taxes plus healthcare costs.

[sjg007]

Would be great. Also would be great if two states could join up and offer single payer together.

[foota]

West coast single payer?

[michaelchisari]

Doesn't seem like a hard sell to get Oregon & Washington on board, politically.

[comex]

But it would require the consent of Congress, per the Constitution:

"No State shall, without the Consent of Congress... enter into any Agreement or Compact with another State."

I don't see that happening.

[foota]

IANAL, but the wikipedia page on Interstate Compact states that "Not all compacts between states require explicit Congressional approval - the Supreme Court ruled in Virginia v. Tennessee that only those agreements which would increase the power of states at the expense of the federal government required it."

I'm not sure this would cause the federal government to lose any power, especially if the ACA was repealed.

Also, if the bill allowing for interstate healthcare exchanges were passed it would seem to imply that states are allowed to cooperate on healthcare?

[sjg007]

It would be great if it goes this way. I would guess that the Feds would sue to stop it in spite and to protect insurance companies and then it would go to the Supreme Court.

[chrismealy]

WA isn't even meeting its constitutional mandate for funding education.

[Abundnce10]

I'd like to learn more about this, can you provide a source?

[foota]

https://www.courts.wa.gov/appellate_trial_courts/SupremeCour...

[rch]

There are people working on that for the interior mountain states.

[erichocean]

I'd be okay with single-payer in CA if we implemented the system in Denmark. Great mix of "everyone is covered" with choice/doctor control. I wish more people wanted it. :(

If we're just going to keep doing the ACA, no thanks. What a piece of shit that legislation turned out to be.

[toodlebunions]

Great point.

It would be good as a baseline, then companies can offer supplement plans for additional coverage or a wider network, similar to Medicare.

[jbhatab]

Here's the only thing I'm confused about. Do we have examples of the government running a service better than the private sector?

I'm not 100% on this, but it seems all of the best aspects of American services come from competition and letting capitalism thrive.

Would love a counter opinion.

[enraged_camel]

You would do well to start questioning the idea that the private sector does anything "better". After all, it was them that gave us Enron, Deepwater Horizon, and most recently, the subprime mortgage crisis, which brought the entire world economy to its knees. Those are only a few examples that spring to mind.

In addition, comparing the government with the private sector is pretty silly. They have different goals. Private companies try to maximize profit, even if it comes with massive externalities (which, barring regulations, they happily pass on to others). Governments aim to serve their citizens, even if it comes at the expense of efficiency. This means that any given problem will be handled very differently by the private sector compared to the government. The route we pick really depends on our priorities as a society.

[refurb]

After all, it was them that gave us Enron, Deepwater Horizon, and most recently, the subprime mortgage crisis, which brought the entire world economy to its knees.

That's a pretty poor argument if you line it up against gov't waste, incompetence and corruption.

[enraged_camel]

Can you provide any arguments (or, even better, empirical evidence) as to why the government has more waste, incompetence and corruption than the private sector?

[refurb]

I'm not arguing one is better than the other. Just that both system are run by humans so I wouldn't say you'd have less corruption or waste in one or the other.

[toomuchtodo]

I can vote out government representatives; I cannot vote out unregulated companies doing damage in a marketplace.

Government provided services provide the opportunity for total transparency; this is not the case in the private sector.

EDIT: @refurb: You're confusing a free market with what the United States has. A free market it ain't (especially regarding healthcare).

[enraged_camel]

Well, yeah, we aren't really disagreeing then.

[r00fus]

I'll take it and democratic representation over corporate waste, incompetence and corruption.

In fact, the reason government sucks right now is that corporations/wealthy have rigged the game by buying representation average citizens can't compete with (legalized corruption = lobbying).

[neltnerb]

Off the top of my head, and certainly some are up for debate. But consider how well these systems worked prior to government intervention.

You may think medicare, for instance, is run horribly -- but I'm pretty confident that seniors are far happier with it than they were pawning off their possessions to get medical treatment prior to it being created.

- Medicaid

- Medicare

- The USPS (which, let's be honest, is freaking amazing for the price)

- Social security

- Basic research

- The military (remember our private security contractors and how much more horrible they were?)

- The fire department

- The police (can you imagine how horrible a private police force would be?)

And on the flip side, consider how atrocious private prisons are compared to federally operated ones.

I'm sure there are many, many others...

[chimeracoder]

> You may think medicare, for instance, is run horribly -- but I'm pretty confident that seniors are far happier with it than they were pawning off their possessions to get medical treatment prior to it being created.

Sure, but empirically, seniors are far happier with privatized Medicare plans than they are with publicly-administered Medicare plans. Original Medicare has the lowest satisfaction rates of all major Medicare plans - far lower than the lowest of the privately-managed plans.

Medicaid is run at the state level, but the same applies there as well - privately managed Medicaid plans are gaining popularity because they deliver better medical results at lower prices.

> The USPS (which, let's be honest, is freaking amazing for the price)

USPS is a mixed bag, but it isn't a straightforward comparison, because the USPS is statutorily protected from competition. For example, by law, all private carriers are required to charge at least twice what USPS charges for a first-class letter - so when you say it's "amazing for the price", we're already dealing with a warped perception of what mail delivery costs.

Most of the other examples you list don't address OP's question ("Do we have examples of the government running a service better than the private sector"), because there hasn't been a private sector for those in modern history for us to compare them with.

[neltnerb]

If the proposals on the table were to simply allow private companies to offer competing options, I would have few concerns that I could back up with factual analysis.

I suspect it would be highly case-by-case, which is fine and how a deliberative legislative body should function. I'd still be extremely leery of private police, military, fire, or infrastructure, it just seems like a transparently bad idea.

Like our security contractors paid by the military, who cost vastly more than public employees and have far less oversight. And who (possibly coincidentally, but come on) are to blame for the worst abuses by our forces overseas.

But for some specific, narrow market (like space travel or health care or even retirement funds) I'd be absolutely willing to give them a chance as long as it didn't break the existing government system.

Charter schools seem like a good case study in that, which I say not because the data completely backs up the idea that government run is always better, but because it's a very complex system with many examples that provide insight in both directions.

[AtheistOfFail]

> Medicaid is run at the state level, but the same applies there as well - privately managed Medicaid plans are gaining popularity because they deliver better medical results at lower prices.

This is disputable. Private companies are also motivated by greed which means they'll cut corners to save penies.

[toomuchtodo]

> Would love a counter opinion.

Every other first world country?

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

[maxerickson]

Several of those countries implement universal coverage using a private insurance model.

[toomuchtodo]

In almost all European countries, its provided by the government and funded by taxation. My point stands.

[maxerickson]

Netherlands, Germany and Switzerland are 3 counter examples.

[unclenoriega]

Germany doesn't have single-payer, but it does have a highly-regulated, mostly public health insurance industry. Most people are covered by the public system, which, while multi-payer, has premiums set by the government and based on income, as well as a fixed set of services determined by the government.

In effect, it's not that different from a single-payer system funded by a progressive income tax. I have thought the German system might be a better fit for the US, since sickness funds can still compete with each other, mostly on customer service and the like.

[luckydata]

All the best systems are single payer. Italy, France, Spain, the UK. The countries with private insurance like Germany are middle of the pack. Clearly single payer is the superior option.

[dx034]

Having lived in both countries, I wouldn't say that the UK system is in any way better than the German system. Rather the opposite.

In addition to that, the German system isn't really a private system. The premium and health coverage is set by law and the insurances are not-for-profit entities. There's the possibility to get private insurance for parts of the population, but you're not dependent on private companies.

[MagnumOpus]

Back that up with numbers please. At best, the former four are better in terms of value-for-money, but with experience living in both the former and the latter, the German system is superior in terms of outcomes, waiting times, choice.

(Yes, mediterranean countries have a higher life expectancy due to diet and physical activity, but that wouldn't change much with a different health care model.)

[maxerickson]

My primary contention is that Every other first world country? is a little too lacking in nuance, I wasn't trying to express an opinion about what works best.

[r00fus]

Parent comment still addresses the point. Majority of first-world countries have single-payer model. Exceptions prove the rule.

[FullMtlAlcoholc]

Prisons for one.

You seem to misunderstand the role of governments though. Citizens and taxpayers are not shareholders seeking to maximize return on investment. The government exists to provide for national defense, rule of law, postal service, and domestic security. Private industry would have an incentive to not provide these services for free riders (the poor, those who dodge payment, etc.)

Private industry also ignores externalities in their pricing, which is why we have regulation. I quite like not having to pay for relatively clean air.

[alexqgb]

Many. Start with highways, aviation safety, and prisons. Oh, and the history of private fire departments is a carnival of horrors. I mean, the list goes on (and on, and on).

[chimeracoder]

> Here's the only thing I'm confused about. Do we have examples of the government running a service better than the private sector?

Medicare is a good case study, because Medicare has both publicly managed plans and privately managed plans.

As it turns out Medicare Advantage (the privately managed plans) consistently beat Original Medicare on the three primary metrics: cost, medical outcomes, and patient satisfaction scores.

(In fact, Original Medicare has the lowest satisfaction rates of all major Medicare plans).

[tylersmith]

Even easier if people could just let others take care of _every_ whim. If there was a guaranteed income there wouldn't even be a need for entrepreneurship!

[thescriptkiddie]

If anything, people would be more likely to start their own businesses if they had a guaranteed income, because it would mitigate the opportunity cost of quitting their day job.

[tylersmith]

Yes they would be more likely, but they wouldn't need to.

[FullMtlAlcoholc]

If you'd like to see what people actually would do with money provided by a basic income program, here are the results of a survery conducted by GiveDirectly, a company piloting the idea in Kenya.

It seems that despite your conjecture, there are a number of people investing the income into education, fishing nets, seeds for crops/livestock, fishing nets, beauty salon's, etc.

In my experience, poor people are the world's greatest entrepreneurs. Every day, they must innovate in order to survive. They remain poor because they do not have the opportunities to turn their creativity into sustainable income.

[tylersmith]

I feel as if there was a misunderstanding, because I fully agree with you.

[__realtime]

the interesting thing to me is why didn't CA make these moves under Obama if they thought they had such a better plan for healthcare... either way it's a win for DT

[neltnerb]

Urgency does wonders for the political process.

[wavefunction]

Donald Trump would love to claim some sort of credit, I'm sure.

Fortunately the world moves on independent of his desires.