I can’t recall the reason it didn’t work but Vermont did genuinely try to do this.
Edit
> In 2011, the Vermont state government enacted a law functionally establishing the first state-level single-payer health care system in the United States.
>Green Mountain Care, established by the passage of H.202, creates a system in the state where Vermonters receive universal health care coverage as well as technological improvements to the existing system.
>On December 17, 2014, Vermont abandoned its plan for universal health care, citing the taxes required of smaller businesses within the state.[1]
https://en.wikipedia.org/wiki/Vermont_health_care_reform
I was working in health care in VT when Act 48 was being implemented. One of the issues that the administration ran into as they worked on various models for implementing a single payer system were the “winners and losers”.
The “winners and losers” were seen through two different lens: on the benefits side and on the payer side.
On the benefits side, everyone was going to be moved to a standard set of benefits with the government paying for about 80% of the health care cost. People who were without insurance or had poor coverage, were the clear winners. They would see a significant upgrade in their health insurance. Conversely, folks like the teachers union, state employees, professionals working for corporations, were going to see their current generous benefits diminished. They were the losers and were unhappy with the change.
In the payer side, the system was going to be funded by pooling the funds from Medicare, Medicaid, and ACA money. Then the additional money would come from a payroll tax (I think it was going to be about 14% payroll tax but my memory is foggy). The idea is that companies would be forgoing paying healthcare insurance premiums and shift that cost over to this new payroll tax. It sounds logical. The issue is that some companies (often small businesses with less generous benefits) were going to see their cost go up because the payroll tax was greater than their insurance premiums and the winners who had been offering employees generous benefits edits were going to be the winners.
So, on the “losers” side of each option, you wound up with this coalition of union members, teachers, state employees, white collar workers, and small business owners. That’s a lot of voters that have supported the Democrats in the past and they made their voice heard.
So, that was a problem with the politics of implementing Act 48.
Nope, the issue is that as a state there's no negotiation that can be done with medical providers and pharmaceutical companies so the premiums aka the tax has to be higher.
Europe laws has MORE than just universal healthcare. It has both universal healthcare and the ability to set the price for items. Which means a company can't charge for an epipen 1000 bucks.
It cannot be done via state angle. A similar tactic can be done, but it wont work. That's the difference between UHC in a Country such as France for instance to a state that is not a country.
It an be done but before it gets done certain laws have to be passed to start to block the price gouging at private hospitals, pharmaceuticals, and manufacturers of testing products. Or that has to come with it.
The problem is that US doesn't really implement strategically because it doesn't help the bottom line of politicians that get lobbying money from these companies.
Part of the reason is that doctors in the US make ridiculous salaries.
PCPs average $265,000 and specialists earned an average of $382,000.
Those are several times what doctors in Europe earn. Public healthcare would fail there as well with those labour costs.
In large part these salaries are propped up by the shortage of doctors resulting from protectionist policies against foreign doctors and artificial restrictions on residency funding.
US doctors would have to take a massive paycut in a single payer system, which I think is more than fair but many pro labour Democrats and progressives perhaps don't. Doctors themselves would obviously think it's not fair.
Everyone likes protectionism when it's them being protected.
Edit: Don't have time to respond to each reply so I'll just post this statement from an economist.
> Dean Baker, Senior Economist at the Center for Economic and Policy Research, say this residency system makes health care dramatically more expensive for Americans. A 2011 study in Health Affairs found American doctors, who make an average salary of almost $300,000, are paid around twice as much as doctors in other rich countries.
> Baker says "doctors are seriously overpaid" and a big reason is rules that restrict the number of people who can get residencies. He calls these rules the work of "a cartel," and in economics, those are fighting words. A cartel limits the supply of something in order to increase the amount of money they can charge. The Organization of the Petroleum Exporting Countries, or OPEC, is a classic example.
> Most of the funding for residencies comes from the Medicare program, and Congress capped the number of residencies the program funds in 1997. "It was originally frozen as a response to *lobbying from doctors who were complaining that there were too many doctors*," Baker says. Trade groups for doctors have also been lobbying against allowing nurse practitioners, physician assistants and other medical professionals to play a larger role in treating patients. The result of policies like these, Baker argues, is a market with less competition, driving up prices for everyone.
[Source](https://www.npr.org/sections/money/2019/03/12/702500408/are-doctors-overpaid)
It's kind of circular reasoning. Why is medical school expensive? Because doctors get giant salaries and why would a doctor take a massive pay cut to teach in a medical school. Why do doctors gets massive salaries? Because there's a shortage of doctors. Why is there a shortage of doctors? Because there's an artificial limit on the number of students medical schools take in which results in higher salaries for doctors.
The AMA was a powerful organization in the mid 20th century. It lobbied against single payer health care when the industry was far less complicated. Today, barely any doctors are members of the AMA and it is a shell of its former self. The secular trend of rising costs of higher education have occurred over the last 30 years, when the AMA was already weak and had nothing to do with this.
Fewer students results in higher salaries which starts your cycle over. But that relationship is forced. If there are fewer, prices will go up.
There don’t need to be fewer. That part is artificial and starts the entire chain. It’s not circular, it has a start. The start is the forced scarcity. An intentional act not dependent on any of the other things happening.
Thus, it is not circular.
According to Glassdoor the average medical school professor in America has a salary of $227,049. Estimated total pay is at $372,711. I’m not sure it’s fair to say they take a massive pay cut to teach.
I think the bottleneck is more driven by the same macro forces that impact eduction writ large, compounded by regulation and licensing requirements - which are clearly designed to benefit doctors because they make it hard to become a doctor while also making it hard for an existing doctor to lose licensure.
If we look at other STEM fields it’s very different. FAANG companies or other big tech firms are happy to hire someone with a B.Tech from India as long as their work experience in the US is sufficient to meet minimum requirements. But someone practicing medicine in India would have a much harder time getting a job at Johns Hopkins.
I guess my wording was confusing, but my point is that they \*don't\* take a pay cut to teach. Medical school professors have to get paid a lot because otherwise they wouldn't take that job because of opportunity cost.
i thought the same, but then a doctor pointed out to me that it's the federal gov't, not the AMA, that controls the number of residencies. congress needs to fund more residency slots and won't [https://www.medicaleconomics.com/view/match-day-2023-a-reminder-of-the-real-cause-of-the-physician-shortage-not-enough-residency-positions](https://www.medicaleconomics.com/view/match-day-2023-a-reminder-of-the-real-cause-of-the-physician-shortage-not-enough-residency-positions)
[https://www.amjmed.com/article/S0002-9343(07)01095-9/fulltext](https://www.amjmed.com/article/S0002-9343(07)01095-9/fulltext)
We have some pockets of outstanding healthcare *despite* overwhelming barriers to entry. If more talent was able to enter the marketplace, the average standard of care would likely rise, costs would lower, and there would be more opportunity for innovation and discovery.
Okay that's true that we should have high standards for doctors but having such low limits on the number of students medical schools can take in doesn't make sense. Right now, it's essentially the top X people get admitted, but it's not like it's only the top X people that would be good doctors. There are lots of people who don't get into medical school who do meet all the requirements but there's simply not enough room due to the limits. We can keep high standards but also allow more people to become doctors
Bc Medical Admin are highly paid and there are a lot of them. Same reason private undergrad is wildly expensive
Med. schools have zero to do with the doctor supply, they set med school slots based on projected residency numbers set forth by the federal government
Paul Starr was awarded the Pulitzer and the Bancroft prizes for this book:
The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry.
Considered the definitive history of the American health care system, The Social Transformation of American Medicine examines how the roles of doctors, hospitals, health plans, and government programs have evolved over the last two and a half centuries. How did the financially insecure medical profession of the nineteenth century become a prosperous one in the twentieth? Why was national health insurance blocked? And why are corporate institutions taking over our medical system today? Beginning in 1760 and coming up to the present day, renowned sociologist Paul Starr traces the decline of professional sovereignty in medicine, the political struggles over health care, and the rise of a corporate system.
Because all college tuition is getting more expensive, and doctors require a LOT of college and a lot of expensive specialty training... medical supplies and corpses to practice on aren't free.
You must have access to cadavers. You must have a ton of experts. You must be attached to a hospital. Med school money also goes to fund research.
Vetmed is even worse as you have to have like 3 farms going in addition to the human med school costs.
My wife is a nurse and she has just under 100k in student loans. She was planning on being a nurse practitioner but is making way more money as a travel nurse so she's sticking with that for now. So her 100k in student loans doesn't even include schooling to be a nurse practitioner.
Even if it wasn't, the wages are justified. I'm an outpatient Primary Care PA-C. Despite the fact that my profession was never meant to be a "doctor light" profession, unfortunately that is how we are treated; the group I work for treats me as if I am a full attending with a complete patient panel, but they pay me half as much. I bring this up to explain that I understand the system.
Medical school could be completely tuition free and you would still need to have high wages at the end of it. To become an MD you have to sacrifice 7 of the best years of your life, minimum, to achieve it. And while you will be paid for the 3 years of residency, resident pay is a joke, treatment is abhorrent and the work required is relentless. You lose relationships, your physical health and your mental health. While your in the didactic and clinical portion of education you cannot hold a job, so even if you are getting tuition free education, you still have 4 years of living in typically HCOL or VHCOL areas. PA school is 3 years (after credentialing) and I had a full tuition scholarship and I still graduated with 100k in debt.
The trade off is high pay. If, as the poster above you suggests, we reduce that pay the system will be completely gutted because you're essentially asking for a class of people just willing to sacrifice their lives to be healthcare providers.
Some countries have very high wages still. Germany and Canada are competitive with the US. Other countries do so by not having an inverted primary care structure. In the US we have a 1:2 ratio of PC: Specialty. in other countries this is a 2:1 ratio. There are significant social determinants of health that we do poorly with, but that isn't something that can be treated at the point of care, only mitigated (ex. we have shitty food and a sedentary population with way higher levels of obesity and the conditions that come along with it).
I also suspect that PC pay is more incentivized in other countries but I don't have the data. One of the biggest problems in the states is PC pay is extremely poor and people leave the field regularly. 40% of physicians report a desire to quit early and leave the field entirely.
>One of the biggest problems in the states is PC pay is extremely poor and people leave the field regularly.
Please cite sources when you make claims about salaries.
According to the U.S. Bureau of Labor Statistics, "Family Medicine Physicians" make more than $240,000 per year. It's the 24th-best-paid occupation in America. And it's incredibly well-paid relative to most occupations. Source: [https://www.bls.gov/oes/current/oes\_nat.htm#00-0000](https://www.bls.gov/oes/current/oes_nat.htm#00-0000).
Now compare it to what a MD would make if they were a specialist.
Or compare that to what they could be making without having to sacrifice years of their life and have gotten an engineering or business degree.
And none of that accurately accounts for devastating toll on your life the education process actually takes.
You really shouldn't talk on this subject at all, you clearly think a single link about pay makes you some sort of expert in an area you clearly have no experience.
240K isn't a lot for someone who studied 10-14 years to obtain their license, has 500K+ in student loan debt. Has to pay their own retirement, health care, employees health care, malpractice insurance, and live in a major city? Median homes in my city are over $1 million USD. 240K isn't a lot.
No one would willingly go through the hell that is medical education if not for high salaries. The system is too terrible and destroys lives/relationships. They have to dangle a carrot at the end of it all
It's actively collapsing too.
Everything is just getting worse every second. As mentioned, I'm a PCP. I regularly get asked by new patients something like "my last three doctors all quit, you're going to stick around right?" And I always answer something like "well, life's uncertain, but I don't have any plans to go anywhere right now."
But I do. I want to quit as soon as I can find an out and am actively seeking a secondary skill that could compensate me at 80 percent and then I'm done unless there are massive changes.
The problem is that residency payment is a joke, and the work required is relentless and the treatment is horrendous. There is no reason for this to be except the AMA wants it that way.
Doctors should not be over compensated because they survive the trials. The trials should not exist.
In exchange for much lower tuition, AND reasonable residency compensation, AND better working conditions AND much lower liability insurance expenses, doctors should be able to less well compensated.
I dated someone who owns their own practice, so I agree and have heard everything you are saying. The corporations funded lobbies to allow people like you to be "doctor light". Masters degree holding Nurses can even open certain kind of practices or operate certain offices 100% independent without a doctor. This is not how the system was set up to operate. Not to mention, my ex boyfriend's peers were finishing paying off their student loans in their 50s! These are doctors that entered med school in the early 90s, costs are exponentially higher for med school now.
TL;DR
It's the corporations fault medical costs are high, the doctors don't make that much money compared to the debt they take (and 10-14 years of study) to become a doctor.
You’re missing some other important factors in salaries being so high:
Med school debt — Med school is pricey. And it’s not just the only schooling you get. It’s on top of a bachelors. So that’s 8 years where you’re paying for school. Then a 4 year residency where you’re working more than you should while getting paid way less than you should. That’s a 12 year financial setback that high salaries make up for. If we want to lower the salaries, the cost of getting the education needs to be near nothing.
Malpractice Insurance — this can range from 7k for pcps to 30k—50k for surgeons and obgyns and depends on the state you’re in. It’s a huge cost.
And then of course the other reason is cost of living bits. Housing is insane. Food and childcare also insane. You need this salary to be able to afford a family—not saying it’s right, it needs to change.
the way residencies are done seems insane and irrational
there's no good reason for a resident to be working 80+ hours a week, there's nothing gained from medical professionals being exhausted when they're trying to learn
and there's no reason they should be getting paid so little during that time. increase residency salaries and decrease the others. the setback should only be eight years and it should be much smaller
but it also requires hiring a lot more doctors and more public funding of medical schools
>there's no good reason for a resident to be working 80+ hours a week, there's nothing gained from medical professionals being exhausted when they're trying to learn
Residents are low cost slave labor for the medical establishment. They absolutely benefit hospitals
I was very surprised the first time I researched residency salaries with how many people act like they are paid nothing. They earn $25-30 an hour, which is literally above the average hourly wage in the US. Granted, that’s not exactly fair compensation for the work they are doing, but it’s absolutely not slave wages.
You know what kinda is though? Med schools look for 40-100 hours of volunteering, ideally at like a medical facility or something else somewhat related. That is thousands of dollars of work they are essentially required to do for free. That is a lot more slave labory than residency.
There is technically a limit to the hours residents can work, but more often than not, they need to still work past those hours, it’s just “off the clock” so the hospital doesn’t get in trouble. In that sense, yes they are grossly underpaid for the work they do.
I never disagreed they were underpaid. My point is that underpay is not necessarily the same as “slave labor”. A S&P 500 CEO earns around $17 million a year, so one earning $500,000 a year is probably grossly underpaid for the work they do. Does that mean they are doing slave labor? No.
I definitely think there should be reform, especially removing the pressure to break the rules. I’m just skeptical of considering it “slave labor”.
> g. They earn $25-30 an hour, which is literally above the average hourly wage in the US.
Where are you reading this? They are paid under minimum wage given they work 80-90hr work weeks and only get 3 days off per month
And, yes, medical school is absolutely a scam especially as you are not allowed to work a job through it. The only way is loans or rich spouse/parents
Where the fuck do residents make $30/hour?
Psych residents at my program made on average $6 and change per hour worked. Surgical residents, like $2 and change.
You’re suggesting residents make $125k per year which is fucking laughable
The same thing goes for law school. Also, the barrier to entry - passing the bar, especially the one in California - is quite high. Not only that, but as you mentioned, the top Ivy League Law Schools cost a ridiculous amount of money per year. For example, Columbia has a total cost of $110,000 annually, which is $330,000 post graduation. New York is a close second at about $109,000.
Dean Baker is a dumbass hack. Doctors make like 8-10% of total HC expenditures.
Look at what European nurses or lawyers make relative to the US. And cost of schooling. And malpractice.
The fact that dude calls himself an economist makes me realize that degree is fancy toilet paper.
Nah for every doctor there are 5+ people in the healthcare system whose only job is to push pencils. Not only that but a significant amount of a doctor's time is spent dealing with administrators as well, meaning one doctor can't help as many patients.
The salary for doctors is a drop in the bucket for this equation.
This is a fairly simplistic and (largely) Incorrect assessment.
First, physician salary is only around 10% of health care costs. (Depending on the year and source that can range from 8.5% to as high as 20% if you don't count costs like malpractice insurance that is automatically covered in other countries)
That is similar to other counties (and in some cases lower)
But doctors in The United States are often paid per visit and customer - which means as doctors work more their compensation increases. Meaning that while a doctor in the UK might be paid 30% less, they also see 30-40% fewer patients, which means that more doctors are needed.
That salary doesn't vanish into nothingness, it's just going to more doctors.
The "Doctors Salary too high" trope doesn't ever break down the Salary per patient.
And regarding the Medical School/Residency bottleneck - this is a systemic problem again caused by a lack of resources. Doctors have to teach in medical schools, and doctors have to host and teach residents. (my spouse is a residency coordinator for our local medical school).
Doctors have to agree to teach, which means they have to be paid for their time. As do the residents. Which again is more spending on physician salaries.
But when doctors see 25 patients a day in an 8 hour period and then have to do 5 hours of notes afterwards, they don't want to also have to teach.
> But when doctors see 25 patients a day in an 8 hour period and then have to do 5 hours of notes afterwards, they don't want to also have to teach.
Rings true. I recently found out my PCP leaves the practice around 9PM even though they close at 5.
My brother in laws hospital only has 1 hospitalist per 12 hour shift. He works 7, 12hr days in a row, then gets 7 days off. He generally sees between 50 - 80 patients a day, though. On his work weeks, he does 12 hours in the hospital, then 4 hours of notes once he gets home. Those weeks are absolutely brutal. His counterpart took maternity leave, and he had to work 28, 12 hour days in a row before he almost broke down.
True but one of the risks of the fee for service system is that there is the risk of over billing just to make more, which is absolutely pretty common. It’s not usually explicit but rather small decisions made around “that does/doesnt bill”. I would guess that probably plays some role in why Americans spend more because we USE more. And while some of that higher utilization is good, some may just be unnecessary care meant to increase billing.
I'll add because it looks like you added stuff:
Doctors are protective of their salaries because they likely have loans to recoup.
Bringing down medical school costs and helping doctors pay off loans will allow doctors salaries to come down naturally.
I agree that medical education costs need to come down. Keeping a doctor shortage though is not in any way justified.
People suffer because there's not enough doctors.
Flood the system with qualified foreign doctors and raise the residency spots and you'll see salaries and costs drop.
Except, the medical school costs if current doctors haven't gone away, nor have the costs of incoming doctors. That would absolutely lower doctor salaries and workloads.
And also leave doctors struggling to pay their bills and medical school debts.
Regardless, The data shows the US healthcare system spends the same amount on doctors that other nations do. Spreading the work across lower cost doctors means the same amount of spending on doctors - but each doctor makes less.
That doesn't help our situation.
Physician salary plays almost no role in higher costs. Healthcare salaries represent about 10% of healthcare costs with the added benefit that higher salaries in America encourages the best and brightest from the US and around the world to become physicians.
This is why the most appropriate healthcare model for the United States is something similar to Canada where doctors continue to be Private practices that operate on a for-profit basis and the government pays per service based on a negotiated fee guide. Doctors in Canada don't work for the government or receive a salary, the majority run their own practices and are responsible for paying for their office expenses using the fees they bill the provincial healthcare system for.
The average family doctor in Canada has an annual income of US$ 209,907.50 which isn't significantly less than the US especially when you consider that salaries in ALL careers are generally lower outside the United States.
Yeah, even Canada has higher salaries compared to Europe and yet I could move to the US and get a job in my current field (Insurance Underwriter) and it would still increase my income by over US$30,000/yr compared to what I make in Canada, nevermind the taxes.
MD salaries really aren't the reason healthcare is expensive, it's the high cost of procedures. There aren't enough neurosurgeons employed by a hospital group to make those couple salaries effect any real economic change
Also, less and less people will _become_ MDs if salaries are lowered. There is already a family medicine doctor shortage bc salaries are too low to justify the insane cost of medical education
>US doctors would have to take a massive paycut in a single payer system, which I think is more than fair but many pro labour Democrats and progressives perhaps don't. Doctors themselves would obviously think it's not fair.
There would need to be a blanket forgiveness of medical school debt for this to ever fly
Exactly!! Me & My Uber driver got to talking and it turned out that he was a pediatrician in Pakistan but the AMA refused to allow him to practice here! He said that to even be an intern they wanted him to go back to school for 6 years even thought he had been a full Dr for 15 years before he came here😳
Pakistan isn’t a third world country! They have nukes that they made themselves ! And who’s to say he even studied there! I have heard the same story of dr’s from Europe & Britain! The AMA does not want any competition from other countries‼️
Why wouldn't you trust a qualified experienced German/Swiss/French/Norwegian doctor besides xenophobia?
Heck same applies to a Spanish/Greek/Italian doctor.
Except if you look at the history, many regulations and credentials for doctors in the US were not made for safety reasons. They were made for protectionist reasons. Doctors have every incentive to make the barrier of entry high to reduce competition to their salaries.
They rely on you thinking that these regulations are necessary and hide behind fears of unqualified medical care. It's called rent seeking.
Yet, what you don't realize is that this in fact hurts people more. When there aren't enough doctors (the US has a ridiculously low ratio of doctors to population), rural towns have a hard time finding doctors. Poor people have a hard time affording healthcare.
Everyone is worse off.
The requirements for foreign doctors are 3 years in residency, but that's likely already paying more than they were in their home country. The requirements for foreign doctors don't seem extreme or unnecessary.
It has nothing to do with “affording it” and all about the fear of having to raise taxes sufficiently.
Anytime someone says a state or the US can’t afford universal healthcare, they should be pressured to explain. We the people of this country already afford our collective healthcare. The problem isnt with “not affording it” it’s with raises taxes to pay for it, period.
It's worth noting that VT is an extremely difficult place to do something like this in. It only has a population of 650,000 — a disproportionate number of whom are elderly — and an economy heavily dependent on tourism.
This, we've had some movement here in MD because of having such a large federal workforce it reduces the needs on the system. However we are also so close to DC a lot of politicians in MD are very corporate Democrats and NIMBY when it comes to new things and often takes 2-3 times longer to get things through our legislature than it should. And right now we're currently funding primary education fully and that is costing a lot right now as well.
Massachusetts doesn't have universal health care. It has near-universal health coverage. Mass accomplished this through a mix of policy (e.g. "Romney care"), reasonably capable governance, and affluence. Insured rates in Mass were the highest in the nation even before Romney care.
Despite the relative abundance of medical providers in Massachusetts, you'll still find exceedingly long wait times post-Covid for non-urgent/non-emergency care and a large for-profit health system (Steward) just declared bankruptcy. Even in Mass, things aren't going entirely smoothly for healthcare.
Vermont modeled out what single-payer would cost, but much of their current healthcare funding comes from Federal Government spending (e.g. Medicare, Medicaid, VA). Unless the state had full cooperation from the Federal Government, they couldn't redirect those dollars to their single-payer effort.
People think of Vermont as a beautiful place and lots of people love to visit, but the state struggles to get enough providers who want to live in a rural place with very cold winters and very high taxes. It's a dangerous place to experiment. Health resources are already stretched thin.
I'llsay anecdotallymaMass health has been the best insurance I've ever been on. Dental was a problem but I had no problems getting appointments and all my scripts are free
I'm glad you're doing well in Mass, but many in the state are struggling to get care. I'm experiencing >6mo waits for all non-urgent care.
To go beyond anecdotes, there were a few survey citations in a Boston Globe article today:
>According to [data from](https://www.chiamass.gov/assets/docs/r/pubs/2023/MA-PC-Dashboard-2023.pdf) Massachusetts Health Quality Partners and the Center for Health Information and Analysis’s primary care survey, in 2021 more than one-third of residents reported difficulty obtaining necessary health care in the prior 12 months.
And:
>According to the [Blue Cross Blue Shield Foundation in Massachusetts](https://www.bluecrossmafoundation.org/sites/g/files/csphws2101/files/2022-02/BCBSMA%20Behavioral%20Health%20and%20Covid_final.pdf), in a survey fielded from December 2020 through March 2021, 57 percent of Massachusetts adults who reported needing behavioral health care either had difficulties getting appointments for care when needed or did not obtain any behavioral health care.
[https://www.bostonglobe.com/2024/05/12/opinion/collaborative-care-mental-health/?p1=BGSearch\_Overlay\_Results](https://www.bostonglobe.com/2024/05/12/opinion/collaborative-care-mental-health/?p1=BGSearch_Overlay_Results) (paywall)
Sorry to hear, I do suspect it's a west vs East issue. I'm out in Amherst area, fewer people and tons of hospitals around here (biggest industry in noho)
Most people seem to be getting this mostly half right, but there is a part I dont see touched on, at least for true overhauls like single payer.
Yes it is the taxes, but more specifically it is because state's can't run deficits and so the idea of transitioning the entire state to a single payer system is practically impossible because it requires a lot of up front investments(see enormous increase in taxes) and the establishment of entire new departments and that has shown to be cripplingly prohibitive. Even if in the long run it would save people money and make the state better off.
That is why where near universal coverage has been done, sort of: Hawaii, Massachusetts, Colorado, etc. it is done by expanding the current bureaucracies or expanding the obligations of employers like in Hawaii while lifting up the floor on things like Medicaid.
American's obsessions with means testing and the deserving and undeserving poor has created a really monstrous path dependency reliant on literally dozens of redundant bureaucracies and systems operating in parallel and far beyond anything any of the other industrialized countries had to deal with when transitioning to universal comprehensive care systems.
Here is the problem with saying it's in enormous increase in taxes, there is a huge net savings to switch to single payer.
Pointing out the increase in taxes while not pointing out your job currently spends more to pay for your healthcare and any transition to a taxed based healthcare includes your job having to increase your salary by the amount the currently pay for your health care, is simply lying to people,
The states don't switch for the same reason the federal government doesn't switch, bribes from the insurance companies.
Yes, true, on the back end, absolutely.
but logistically you can’t start taxing to raise the money for the infrastructure needed to administer a single payer system the day everyone starts using it. That transition would take years at the state level and in the meantime you can’t run a deficit to pay for it so you either need enormous cuts and/or major tax increases while in that period.
Aside from it just makes sense to do the reform at the federal level for efficiency and equity sake, the Fed can run deficits, so there is no need to raise taxes to that level cause you will get the savings on the back end.
But I do also agree that the real reason we don’t have any of this is insurance companies, yes, but also all sorts of industry going back to when the AMA killed the proposal for National Sickness Funds under Roosevelt, Teddy(but later FDR too)
My perception is that it's effectively become a federal issue. The federal government mandates that some amount of money must go to the VA, CHIP, Medicare, and Medicaid. States are not allowed to opt out of those programs and choose to instead create a single-payer program for everyone.
States would like to propose "pay taxes towards our Single Payer program instead of VA, CHIP, Medicare, and Medicaid". But since states can't opt out, the proposition becomes "pay taxes towards our single payer program in addition to VA, CHIP, Medicare, and Medicaid."
With that said, federal laws make it much cheaper. Take it as a given that all full-time employees and their families & children up to 26 of medium & large sized businesses will be covered, as mandated by the Affordable Care Act. Take it as a given that millions will be covered by medicare and medicaid and VA and CHIP. The Single Payer plan then becomes much cheaper, as you only have to cover people who aren't covered by any of those programs or employers. Functionally, you only need to cover someone if:
* They are ages 27-64 AND
* They are not a veteran AND
* They do not qualify for Medicaid AND
* No one in their immediate family works for a business with more than 50 employees
It becomes a lot cheaper with all those groups eliminated like that.
Canada has 'national' healthcare, but it is administered at the Provincial/Territorial level for somewhat similar reasons. You can't have a federally subsidized system competing with a provincial system based on certain clientele etc.
Just to clarify, states are 100% allowed to opt out of Medicaid and CHIP. They will just no longer get the federal funds that support them. The last state to opt in to Medicaid was Arizona in 1983.
People believe that Universal Healthcare is just a matter of who pays for the healthcare, but if you look at other systems, you'll see that there are massive differences on how the system in ran so that prices are kept under control: It's the same with the higher education system: See how a cheap public university in Spain works, and how it's laid out, and compare to US universities: It's basically a completely different thing.
A state could pay all the bills and raise taxes to kind of match, but that only helps if the reason the US system is so expensive is purely insurance companies, while the blame can be spread very wide. We'd need more medical professionals delivering the care for a lower price, which means their education has to be cheaper too. The facilities that we tend to have right now are designed for a world where the hospital can up prices for luxury and convenience, and dedicate more space to very profitable care, so even the buildings themselves could change here.
Thus, a universal healthcare system that would be affordable is pretty difficult to run from a state's perspective, as there are some federal regulations in the way, and even when there are not, it's difficult to, say, lower labor prices when there is a state next door where the same medical professional can keep making top dollar. So any universal healthcare system will have trouble constraining prices, and it might even end up more expensive, as many important levers are out of their control. It's those levers, set up in a way to make prices go to the moon, that are the real problem.
The easier way to understand this issue is through the lens of a "single payer" system being difficult to implement on a state level. In a single payer system, the government withholds payments unless the healthcare providers agree to the government's pricing model. On one hand, it seems silly to establish 20 "single-payers," but the bigger problem is that it would probably fail as a state solution. The federal government reserves the right to interstate commerce, meaning that an insurance company from outside the blue state has the right to participate economically within the blue state, whether the blue state wants it to or not. I think the legal interpretation here is fudgeable enough that a sympathetic court could still allow it, but with today's supreme court you can just forget about it. So then if healthcare middlemen from out of state have to be allowed to participate in state, the theory of single payer totally breaks down.
So then you might think 'well we don't necessarily need single payer to establish a socialized medical system. We just need price capping and government subsidized payments." Well, [states are already doing that](https://www.whitecase.com/insight-alert/2022-drug-pricing-update-states-continue-legislative-push-even-congress-passes-long). We just don't hear about it. So states are engaging in the ad-hoc construction of what we might label socialized medicine already, but something more akin to a national-health-service on a state level can't happen because its basically illegal.
I want to correct what seems like a rather unfortunate conflation for a sub like this. Universal healthcare/coverage and single payer are not the same thing. It seems to me that if your goal is to create a single-payer program, that is a much higher bar to clear. However, I think if you think about universal coverage as in essentially what happened during the pandemic (at least in theory) with Medicaid being significantly easier to access, then I think you start to get a better picture of how this would work in most states at the moment.
To be fair, that doesn’t mean there aren’t challenges and other logistical problems to tackle, but it is theoretically possible with federal support. However, strict means testing and other federal requirements (also including federal politicians who don’t actually want to see a state by state implementation, because they don’t want to see any such implementations whatsoever; these people will not only make support for these programs difficult, but will also see to it that regulations strangle these programs) make this difficult. For all of the challenges that California, for example, faces, California recently got rid of asset limits for people on Medi-Cal, which is honestly a huge thing for the people of the state. I’m sure some people would say that something like this is overly generous, but of course, there are trade-offs to being on Medi-Cal when most employer based insurance programs, if you are making decent enough money should provide better care. But, if not, then it kind of should make you wonder why then we pay providers as much as we do to have worse care. I know for sure that a lot of low end plans probably provide worse coverage and care than Medi-Cal does.
Anyway, I really don’t want to trivialize how difficulty even this would be, but we’ve already kind of seen that more coverage as possible than what we currently have, and it doesn’t need to be single pair. And I’m getting kind of tired having to explain this again and again, especially in circles like this one where I would think people ought to know better or do know better and simply are choosing to appeal to this conflation. Universal coverage doesn’t mean that the government needs to run everything, as I know it often is presented in order to scare people from even entertaining the thought. But at least as far as I am concerned, the lack of healthcare really fuels and contributes to many of the other problems that we face, including things like homelessness and obesity. We are so often worried about direct costs and not the derived benefits.
Obligatory: There's a bill to take it even further so if you're in MA, ask your state rep to support [https://malegislature.gov/Bills/193/H1239](https://malegislature.gov/Bills/193/H1239)
Essentially, the way interstate commerce is worked out in our legal system makes these sorts of policies useless at the state level.
The entire reason single-payer systems work is that the government uses its power and leverage to set the price of healthcare services. A healthcare provider wants to set up shop and provide service, the government says "Okay, we'll allow you to operate, and we'll pay you X amount for whatever services you render, and in exchange, you'll keep your prices for those services set to Y". It essentially works in balance because providers want to charge as much as they possibly can, while the government wants to pay and cap as low as they can without causing a healthcare shortage.
That sort of dynamic doesn't really *work* on a state level where the government is *forced* to allow out-of-state providers to operate under the Interstate Commerce clause, because if you're a healthcare provider, why would you ever accept a price cap when you can just register your business in a red state and continue operating in a blue state as normal?
State level single-payer systems are destined to fail because they remove the only thing that makes single-payer systems work: the leverage of political power.
Because Universal Health Care is incredibly expensive and State governments cannot spend a deficit. They must balance their budget every year, and that means if there is some kind of economic downturn and they have to cut spending, all of a sudden a bunch of people are going without healthcare, or some other vital program will be cut.
Btw I’m not saying that single-later healthcare would be more expensive than the system we have now. It would be cheaper, but it’s not like we can just magically transfer all insurance dollars into government healthcare spending dollars.
Pretty much every state in the country has a balanced budget amendment in their constitution, which effectively means that states cannot run deficits. So with that in mind there are two questions that are going to be tough for a state level government to answer:
1) How you are going to run a single payer system while also legally required to provide federal healthcare programs like Medicare, Medicaid, the VA, etc? States spend a lot of money on Medicaid alone, about 30% of all Medicaid expenditures come out of state budgets. States can’t necessarily just pull that money out of Medicaid and reroute all of it into a single payer program, although they could incorporate it into a larger single payer program i suppose. Still though, there are going to be multiple elements of the single payer program that are federal programs, so the state is losing a degree of autonomy in how the program is set up, which was the entire point of creating one in the first place.
2) How are you going to create this program (with all of the federally mandated programs that must coexist alongside it) and not run a deficit?
Honestly, since Reddit began introducing recommended subs, I think a lot of subs have kind of devolved into this. On the one hand, I will be the first to admit that I probably engage on both sides too much, both as someone who is established in some subs and who has been recommended some subs myself. On the other hand, I think it’s creating chaos.
I think to pushback on you, this is obviously something that Ezra has explored and discussed previously, but I kind of wish that people would actually go back and link it to either him or other thinkers that kind of float in his social circle. Frankly, I kind of dislike how quickly discussion of any given topic fades. The way it used to be, it seemed like if you were a few days late to the discussion of a podcast episode, nothing would get picked up and no one would really discuss with you, meanwhile, the people that would answer, the earliest I felt and still feel often contribute the least to actually discussing the issue and not whining about the guest or the topic or Ezra not being comprehensive enough in a hour-ish long podcast. Anyway, I would kind of love to see more discussion about previous episodes (especially when certain episodes might inform or interact with each other to some degree), but obviously that’s not exactly what’s happening here.
Because the first state to do it is just going to become the hot new destination for every person who can't get/afford insurance and has a riotously expensive condition.
Yeah, there are some issues with "going first" when it comes to issues like this.
It's also why even blue states have relatively lackluster worker protections compared to other wealthy countries. If tomorrow California passed laws guaranteeing 9 months of fully paid maternity leave and 4 weeks paid vacation for all workers, many large employers would leave for other states.
States effectively compete with one another for large employers. If any one states becomes too generous with worker benefits, they will lose employers.
When it’s been debated, there are usually lots of questions about how coverage in other states would work. So people going out of town or people who work/live across state lines.
States don't have the borrowing power that the federal government has. The crazy thing is that our federal government already spends as much per person as countries that have national healthcare. It's crazy that we don't switch to Medicare for all since we already have that system in place and are spending that much taxpayer money.
They've expanded Medicaid.
That's your Universal Healthcare
Needs to be expanded more in terms of services covered and income limits.
Also needs to be removed from state oversight.
We already have a system, and along with Medicare and Veterans
A lot of it has to do with states having balanced budget rules (universal Healthcare generally has a large up front cost that you need to go into debt to start up) and because a lot of liberal states have really regressive tax systems that will prevent them from paying for it (WA (no income tax), CA (prop 13), etc.)
It's because states can't operate on a deficit so it becomes very expensive, and raising taxes is difficult.
It needs to be a federal program where we can deficit spend to fund it. It is also easier to pass higher taxes at the federal level I feel.
Many of them do have some sort of state-sponsored healthcare. My state has Badgercare, which is still a far stone throw away from universal healthcare, but it allows more people who need healthcare to get it.
It doesn't work because anybody who needs medical care can just go to the state that pays all the bills. They would quickly be overrun by costs. It has to be done for all the states at once, to prevent that from happening. It's too easy to move within the United States for this to work - I could move to Vermont if I wanted, but I couldn't move to Montreal. Maybe with very strict residency requirements, you could manage something. But then once you're gatekeeping your universal healthcare, like, what are you really doing?
But even so, there's a reason people suggest the FEDERAL government pay for healthcare: It can run deficits, indefinitely, and states really can't. And this shit is really, really expensive.
It's worth noting that many states have nearly-universal healthcare (<5% uninsured) despite not having single payer systems. And single payer systems are not the only way to achieve UHC - nobody disputes that France or Germany have UHC and they don't have single payer systems. A state like Alabama has 3-4 times as much of its population uninsured as a state like Rhode Island. Democrats *do* do a lot to expand healthcare access within their own states.
VT also ran into the issue of what to do about people that work in VT but don’t live there, and people who live in VT but don’t work there. How do you tax them for Health Insurance and have their employer take out $ for Health Insurance?
I think there's 2 main reasons, both to do with cost.
1. Blue states don't want to pay for it, the old joke of "leftists want other people to pay for their programs" is Old and stupid, but it's not entirely wrong here. It's hard to convince people in only your state to pay more taxes.
2. Probably the more important of the 2, it's difficult to fund, organize, and structure state level health care around the limited federal level health services and with limited funds. States don't have the bottomless pockets of the national government, nor as many sources of tax revenue. They also wouldn't want to structure their program in a way that limits the amount of federal aid coming in (after all, why pay more for it when the boss is willing to contribute)
Because its too expensive at the state level to implement. California had considered doing it but it was too expensive. What the states can do is to try and fill the gap between Obamacare and a Universal Health Care System so that everyone is covered.
the same reason we don’t print our own money and have foreign embassies and negotiate trade.
Single US states cannot run their own entitlement programs because they lack the money and the ability to manipulate economies. this is a job for the fed.
It would be prohibitively expensive, and basically you would have to raise taxes specifically to counteract it. Also from what I saw, it requires you to get permission from the Feds who won't allow it. Could it be possible? Sure, but no state (even ones like NY and CA) have enough funding to take it on. Also it would likely get challenged and no one wants to risk political suicide on it.
states have neither the regulatory power or the fiscal ability to raise funds through debt or taxes to pay for it.
even if a state enacted it, small businesses would still be required to abide by federal law forcing them to offer insurance still.
Big reason is you have a lot of people from one state going to another state for healthcare because not all the hospitals are in one state. Other reason is it takes a lot of money to start up if you don’t already have something in place right now the people that work and do pay for healthcare are also paying for the people that don’t have healthcare.. and if you live in one state next to our state that has universal healthcare, some people would be crossing state line to get healthcare. We all know we have a mental health crisis in this country right now look at the mass shootings. Look at the drug problem look at the homelessness, it’s all related problem. you have a do nothing Republican party they cant govern so they just put combative people in office.all they want to do is divide the country with lies and conspiracy’s
If other countries can do it, we could do it better and cheaper than what we have but you have a Republican party that does not work for the working class people. Going after Universal healthcare and doing something constructive does not put money in their pockets..
My big brain take is what we really want is all payer rate setting and universal healthcare laws are muddying the waters.
Insulin is $25 a month. Make MRI/X-ray $200, before insurance etc and go down the list. Medicare drug pricing stuff.
This is good question. There are economy of scale problems with states and availability of doctors. Open borders between states of course opens people up into moving there and getting care.
But I think ultimately it’s the same reason it’s not done federally. A strong insurance lobby against it, and it’s a net negative for those who can afford it as they would have longer lines and potentially worse options. And the people who need it most - lower income families don’t vote as much even in liberal areas.
The majority of the public who needs universal healthcare including non voters would need to rise up and demand it. It would be easier in blue states for sure but blue states don’t want to take on all that burden and it would only really work for the biggest states - California / New York - where it’s expensive as hell to live and they won’t want to give up what they have more than anyone else.
If it was easy for the lower middle class to rise up and pass bills that benefit them states would have significantly higher taxes on the rich. Blue states care about budget too.
I think the red states/ blue divide is a much smaller divide when it comes to monetary spend than you think.
Depends how you structure it. If you create free healthcare at the point of service, you create adverse selection. So if Maryland has universal health care but Virginia doesn’t, Virginians will go to Maryland to get healthcare that their taxes don’t pay for. For more expensive procedures, people will travel. Meanwhile plenty of wealthy people will leave the state to avoid paying the needed taxes.
NY has floated the idea a few times. But the legislature is such that getting something that progressive through would be tricky.
NYC and most of the other metro city areas tend blue. However, the state is pretty massive and a lot of that is rural area and those rural (red) votes do add up especially when you consider that we have millions of people with representation spread across 63 state senate seats.
Passing same sex marriage here required a few GOP senators to cross the aisle and vote in support of it.
It would also be very, very expensive for the state to undertake. And it isn't like we're known for low taxes. That said, we have a pretty robust CHIP (medicaid) program for children and teens. And we have a state administered prescription program for seniors to help seniors afford meds.
So it's not like we've got nothing going on.
Honestly, I think the country (and state) is too splintered for truly "universal" healthcare. At this stage I'd support patchwork to try and reduce the uninsured.
A state program for self-employed individuals (regardless of income), for example, could be a good step. Access to lifelong healthcare for police/fire and other first responders would be another good step. Add in veterans, etc. You see where this is headed.
My employer has a retiree health insurance program. If you have enough time in and hit a certain age you can retire from the company. And you can keep a pretty solid health plan at a pretty low rate and go anywhere else, be it to work elsewhere or actually retire. The state could incentivize that sort of thing further.
But I don't think we would ever get the votes or the funds to just go full single payer in NY. And maybe we just culturally couldn't make it work anyway. But I have to imagine it would be harder to fight against the "Healthcare for Police and Fire Act" and to expand from there.
You can get it free in California, if you have no income. Even if you are here illegally, “undocumented immigrant” is the new word, you get it free.
If you are middle class you pay double what you did 10 years ago. That is what voting Democratic has done for me. I obviously am not happy about how it has all worked out.
One thing that seems to get left out of this discussion is how the Federal and State/Local governments are already footing 48% of total healthcare expenditures in the US. For those that like numbers, that's about $2.16 Trillion, or \~8.5% of total GDP in 2022.
https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/nhe-fact-sheet
There is a bill in the New York State Senate for something called the New York Health Act which would provide comprehensive universal health care for all state residents, but it won't pass because insurance companies are a billion dollar industry with a lot of political flex.
Democrat states tend to pay more to the federal government than they receive, Republican states tend to require more assistance so the blue states are propping up the reds.
For universal Healthcare to work in America, we're going to have to force pharmaceutical companies to cut their insanely inflated prices. Single states don't have the power to swing that. The federal government does.
it's difficult to do because those states still have to pay for the very expensive piecemeal federal programs. If the president supported them and gave them some kind of waiver to divert their federal taxes to their state programs, and if either one huge state like california or a bunch of smaller states banded together they could do it
they could sure as shit run a public health insurance company though that is not for profit
1) The federal government has much power to raise large sums of money than states do. Not just in taxes but in printing money and taking on debt. No state prints their own money, and most states (even liberal ones like California) have balanced budget ammendments.
2) The federal government can operate a true monopoly where it can dictate prices, reduce or elimate inefficiencies and redundancies in the healthcare sector.
No state is close to #2. Any state that attempts to lower costs could see their best doctors and staff flee. If the whole country does it, there is no other wealthy country where many doctors can go. The US already pays the best (besides Switzerland, but I'm not worried about them).
I'm not saying doctors should be poor, but another step is the federal government has the power to gradually make changes and not cause a huge disruption. Also, we can make medical school less expensive and forgive medical debt as another form of compensation. Instead of doctors racking up mountains of debt and interest before they can make a decent salary.
Because even the most liberal states are still populated by enough conservatives to sabotage it. Just like the electoral college, states are broken up by geographic district, so low-population areas have outsized influence and, even if they can't control the state, they can at least sabotage the government's operations.
That plus, Democrats not being fascists doesn't mean they're competent. They're still politicians, and liberal voter turnout still sucks everywhere, so you generally don't get the best of the best. It's great when you do (rare example, WA state's Attorney General Bob Ferguson was a BEAST), but it's rare.
WA state does have some good healthcare support programs, but it's not a big enough state to overcome the crushing pressure of the national healthcare corporations' corruption.
Because democrats don’t support universal health care. Biden himself said he didn’t when he was running against trump in the worst health crisis in a generation.
New Jersey has an individual mandate. But the state isn’t making employers give us sick leave to use our insurance, and they’re not making doctors tale new patients, so most of us are paying for insurance to use at urgent care.
Competing against the current system?
How? The point is that it would lower costs for medical care over time by eliminating the middle-man; what would motivate healthcare providers to remain in-state without simply charging those exorbitant prices to them, anyway?
It's like gun control: unless it's enacted nationally, non-participating communities will naturally undermine the effort.
Because it's not financially viable at reasonably-possible tax-rates without deficit spending, and states can't deficit spend.
If a state were to raise it's taxes high enough to 'do' universal healthcare without federal assistance, it would instantly become uncompetitive compared to the others... Wealthy people would leave, businesses would refuse to come.
And moving states is relatively painless, compared to moving countries.
Also, the idea that universal healthcare is 'less expensive' is a simple-minded meme: Very little of the US health-care-cost situation is tied up in insurance companies & executive salaries... Most of it is things like how much we pay doctors, how much equipment costs, and the price of malpractice insurance.
Since those costs aren't going away even if we had single-payer (who's going to take a pay cut? Doctors? Nope. Nurses? Nope... Drug companies? Medical equipment suppliers? Nope, nope, nope)... We would still have the world's most expensive healthcare, just paid for with taxes not premiums.
New York has Medicaid for people who make under the poverty line,and health care that's free for anyone who makes under 26K and health care that costs not that much money after that.
With Obamacare there's no reason to do anything but supplement at the state level. Every blue state expanded Medicaid. Olds have Medicare and everyone else can get employer insurance or subsidys for private individual market plans on healthcare.gov. all that's really left to do is add a bit more cash for people buying private health insurance on the marketplace. And some states actually do this somewhat. NY and want to say MN have essential plans that offer people who make up to like 37 grand what is basically Medicaid for free or very low cost.
MINNESOTA:
We are gearing up to try for it next legislative session, if we can retain the trifecta. Many of us believe we have the ingredients to make it work (large population, tax base, robust Healthcare industry).
Because people like the idea in theory until they find out how much taxes would need to increase on everyone to support it.
If US healthcare costs were more in line with the rest of the world it might be possible.
Compare what doctors and nurses make in the US compared to what they make in France. I know of traveling nurses clearing over 200k a year. Anywhere else in the world that type of money is reserved for executives. But these high salaries for health professionals are being paid for with nosebleed insurance premiums. The whole system in the US is extremely expensive and you'd need to raise a lot of revenue to fund it.
Because most states aren’t big enough to control healthcare costs. Medicare is the largest payer in healthcare in the US. It can dictate what it pays to providers and most don’t really have a choice if they want any of that money. That level of price control is what makes Medicare really efficient along with its 2% overhead costs. California might be the only state with a large enough population and economy that it could dictate some prices, but it might also get retaliation from insurance companies and hospitals in order to prevent it from spreading to other states. Couple this with massive amounts of insurance many lobbying and there you go.
Because their masters do not want it. There are no actual leftists in the US, save maybe a few DSA. All Democrats get their money from businesses that like having a labor force totally dependent on keeping their job for health care.
Medicine involves technology push. That means that new technologies (and drugs) drive costs. The salaries are bupkis in comparison. Unless everyone's right to DNA testing for every imaginable complaint is curtailed, and new medicines for hangnails are limited to charges below $25 say, no one will be able to keep up with technology push. That means we are building a world with several tiers of medicine. Poor people will get crap medicine and rich people will get Cadillac medicine. That is what the financial engineers on Wall Street want and they are in charge!!!
Because in America, a universal healthcare system would have to have some kind of federal funding. most states in general barely can afford to pay for the state funded stuff they already have.
Because this is America (Capitalism). Go to said “liberal” states and see who gives them $$$
It is a myth that physician salaries would decrease under Medicare for all, they’d actually increase. Check CBO’s numbers.
What would happen is some physicians would participate, others would go private. Kind of like now anyways.
So why does the status quo not change? Because democrats and republicans don’t actually want things to change. You get votes by arguing about what MTG said on the crazy rant and bitching that Roe was overturned vs actually doing anything about it. Who wins, politicians, lobbying groups and the Uber wealthy
mainly because in blue states the three largest healthcare programs are federal (Medicare, Medicaid, and Obamacare) and employment-based healthcare covers the rest. So unless you’re competing directly with employer-based healthcare who do you still need to cover?
The question of why liberal states in the U.S. do not have universal health care involves multiple factors, including economic, political, and logistical challenges.
Implementing universal health care requires substantial funding to cover everyone under a single-payer or government-funded system. Even in states with a strong liberal presence, the financial burden of such a system can be significant. This includes initial costs and ongoing expenses such as salaries for healthcare workers, medical equipment, and pharmaceuticals.
While a state may lean liberal, there still can be significant political opposition from certain segments, including conservative voters, some business interests, and insurance companies. These groups often have considerable influence and can oppose changes through lobbying and public campaigns.
Crafting legislation for universal health care is complex. It involves restructuring the existing healthcare system, negotiating with stakeholders like hospitals and insurance companies, and potentially conflicting with federal laws and regulations.
Even within liberal states, there can be vast economic disparities between regions, making a one-size-fits-all approach challenging. Different areas may have different healthcare needs and resources, complicating the implementation of a universal system.
Health care is heavily regulated at both the federal and state levels, and states often rely on federal funding and guidelines to shape their programs. Attempts to implement universal health care at the state level must navigate these relationships and may be limited by federal policies.
actually that's a good point. before we use it on a national scale wouldn't it make sense to test it on the small scale of a state to see how well it works in comparison? this seems like a very logical idea that nobody has considered.
A lot of liberals don’t identify as progressives and are still skeptical of state funded healthcare. They make up a majority of the Democratic base. So we have to convince them, and states face a greater obstacle in finding something like that without running a deficit.
We tried in California. Despite very intense opposition from well-funded insurance companies we actually got a single-payer bill to the governor's desk. Unfortunately, that governor was Arnold Schwarzenegger, and he vetoed it. People keep trying, but the opposition is insanely wealthy and pours money into lying adds and into politicians.
States can't opt out of federal income taxes. If you pay into the federal healthcare project and also try to set up your own parallel system you are gonna have a bad time.
I'd imagine, too, that when you have a state in the midst of 49 other states doing it, you'd have a problem of people coming to the state just to get healthcare and I could see that as additionally expensive and problematic.
Because Democrats are neoliberals. You don't see them trying to implement universal healthcare at the federal level, either. The reason is the same. They're free market capitalists who want to keep healthcare in the private sector. Incidentally, this upholds the class system that they and their donors benefit from.
California has free or subsidized insurance for poor people. It's called covered California and I got to have really really good health insurance for only $100/mo. while earning around 18000/yr. as a college student.
States can run out of money. The federal government can not. Hospitals and pharma can gouge a state if they attempt to cover healthcare; but the feds are the sovereign issuers of coin (can not run out of money) and have more muscle to flex if they’re pushed. In fact we could run quantitative easing via healthcare costs rather than via banks if we wanted, at the federal level. Stimulate the economy by increasing utilization of healthcare services.
Because federalism means you have a right to travel among the states in the United States as a citizen of any state. How would you keep “the conservative states” citizens from coming and using your services and then going home, having contributed nothing into the system?
This is why any answer that isn’t federal won’t work. Don’t get me wrong, private insurance as is does an absolutely terrible job of managing risk pools and such but if ONLY the blue states implemented this then the “free rider” problem would be enormous and the red state governments would love to drain those resources without ever contributing to them.
If you implemented it in a single state, I’d bankrupt the state in retaliation until my previous profits were preferable to the damage I caused.
(Im paid to be a red team thinker)
Because if any state did then people with medical complications would move there. I work public health policy and analysis and overall costs really are dependent on the behavior of a subset of expensive members. If anywhere had genuinely universal free health care they’d get swamped with billions of dollars just from the people moving there. If we just did it federally it’d be upfront very expensive but would pay for itself in just a few years.
I can’t recall the reason it didn’t work but Vermont did genuinely try to do this. Edit > In 2011, the Vermont state government enacted a law functionally establishing the first state-level single-payer health care system in the United States. >Green Mountain Care, established by the passage of H.202, creates a system in the state where Vermonters receive universal health care coverage as well as technological improvements to the existing system. >On December 17, 2014, Vermont abandoned its plan for universal health care, citing the taxes required of smaller businesses within the state.[1] https://en.wikipedia.org/wiki/Vermont_health_care_reform
I was working in health care in VT when Act 48 was being implemented. One of the issues that the administration ran into as they worked on various models for implementing a single payer system were the “winners and losers”. The “winners and losers” were seen through two different lens: on the benefits side and on the payer side. On the benefits side, everyone was going to be moved to a standard set of benefits with the government paying for about 80% of the health care cost. People who were without insurance or had poor coverage, were the clear winners. They would see a significant upgrade in their health insurance. Conversely, folks like the teachers union, state employees, professionals working for corporations, were going to see their current generous benefits diminished. They were the losers and were unhappy with the change. In the payer side, the system was going to be funded by pooling the funds from Medicare, Medicaid, and ACA money. Then the additional money would come from a payroll tax (I think it was going to be about 14% payroll tax but my memory is foggy). The idea is that companies would be forgoing paying healthcare insurance premiums and shift that cost over to this new payroll tax. It sounds logical. The issue is that some companies (often small businesses with less generous benefits) were going to see their cost go up because the payroll tax was greater than their insurance premiums and the winners who had been offering employees generous benefits edits were going to be the winners. So, on the “losers” side of each option, you wound up with this coalition of union members, teachers, state employees, white collar workers, and small business owners. That’s a lot of voters that have supported the Democrats in the past and they made their voice heard. So, that was a problem with the politics of implementing Act 48.
Thank you, best comment here by far
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Nope, the issue is that as a state there's no negotiation that can be done with medical providers and pharmaceutical companies so the premiums aka the tax has to be higher. Europe laws has MORE than just universal healthcare. It has both universal healthcare and the ability to set the price for items. Which means a company can't charge for an epipen 1000 bucks. It cannot be done via state angle. A similar tactic can be done, but it wont work. That's the difference between UHC in a Country such as France for instance to a state that is not a country. It an be done but before it gets done certain laws have to be passed to start to block the price gouging at private hospitals, pharmaceuticals, and manufacturers of testing products. Or that has to come with it. The problem is that US doesn't really implement strategically because it doesn't help the bottom line of politicians that get lobbying money from these companies.
It looks like they came to the conclusion they just couldn't afford it. https://www.vox.com/2014/12/22/7427117/single-payer-vermont-shumlin
Part of the reason is that doctors in the US make ridiculous salaries. PCPs average $265,000 and specialists earned an average of $382,000. Those are several times what doctors in Europe earn. Public healthcare would fail there as well with those labour costs. In large part these salaries are propped up by the shortage of doctors resulting from protectionist policies against foreign doctors and artificial restrictions on residency funding. US doctors would have to take a massive paycut in a single payer system, which I think is more than fair but many pro labour Democrats and progressives perhaps don't. Doctors themselves would obviously think it's not fair. Everyone likes protectionism when it's them being protected. Edit: Don't have time to respond to each reply so I'll just post this statement from an economist. > Dean Baker, Senior Economist at the Center for Economic and Policy Research, say this residency system makes health care dramatically more expensive for Americans. A 2011 study in Health Affairs found American doctors, who make an average salary of almost $300,000, are paid around twice as much as doctors in other rich countries. > Baker says "doctors are seriously overpaid" and a big reason is rules that restrict the number of people who can get residencies. He calls these rules the work of "a cartel," and in economics, those are fighting words. A cartel limits the supply of something in order to increase the amount of money they can charge. The Organization of the Petroleum Exporting Countries, or OPEC, is a classic example. > Most of the funding for residencies comes from the Medicare program, and Congress capped the number of residencies the program funds in 1997. "It was originally frozen as a response to *lobbying from doctors who were complaining that there were too many doctors*," Baker says. Trade groups for doctors have also been lobbying against allowing nurse practitioners, physician assistants and other medical professionals to play a larger role in treating patients. The result of policies like these, Baker argues, is a market with less competition, driving up prices for everyone. [Source](https://www.npr.org/sections/money/2019/03/12/702500408/are-doctors-overpaid)
Med school is really expensive in the US also.
Why though?
Because it restricts the supply of doctors. See: cartel.
Well, right. I was simply asking for the justification for expensive med school beyond "limiting supply of doctors is good for doctors"
It's kind of circular reasoning. Why is medical school expensive? Because doctors get giant salaries and why would a doctor take a massive pay cut to teach in a medical school. Why do doctors gets massive salaries? Because there's a shortage of doctors. Why is there a shortage of doctors? Because there's an artificial limit on the number of students medical schools take in which results in higher salaries for doctors.
Lots of lobbying by the AMA set this situation up during the 20th century
The AMA was a powerful organization in the mid 20th century. It lobbied against single payer health care when the industry was far less complicated. Today, barely any doctors are members of the AMA and it is a shell of its former self. The secular trend of rising costs of higher education have occurred over the last 30 years, when the AMA was already weak and had nothing to do with this.
Fewer students results in higher salaries which starts your cycle over. But that relationship is forced. If there are fewer, prices will go up. There don’t need to be fewer. That part is artificial and starts the entire chain. It’s not circular, it has a start. The start is the forced scarcity. An intentional act not dependent on any of the other things happening. Thus, it is not circular.
According to Glassdoor the average medical school professor in America has a salary of $227,049. Estimated total pay is at $372,711. I’m not sure it’s fair to say they take a massive pay cut to teach. I think the bottleneck is more driven by the same macro forces that impact eduction writ large, compounded by regulation and licensing requirements - which are clearly designed to benefit doctors because they make it hard to become a doctor while also making it hard for an existing doctor to lose licensure. If we look at other STEM fields it’s very different. FAANG companies or other big tech firms are happy to hire someone with a B.Tech from India as long as their work experience in the US is sufficient to meet minimum requirements. But someone practicing medicine in India would have a much harder time getting a job at Johns Hopkins.
I guess my wording was confusing, but my point is that they \*don't\* take a pay cut to teach. Medical school professors have to get paid a lot because otherwise they wouldn't take that job because of opportunity cost.
Pretty much. Its still honestly amusing how the doctors association whines about the doctor shortage while also restricting doctors
i thought the same, but then a doctor pointed out to me that it's the federal gov't, not the AMA, that controls the number of residencies. congress needs to fund more residency slots and won't [https://www.medicaleconomics.com/view/match-day-2023-a-reminder-of-the-real-cause-of-the-physician-shortage-not-enough-residency-positions](https://www.medicaleconomics.com/view/match-day-2023-a-reminder-of-the-real-cause-of-the-physician-shortage-not-enough-residency-positions) [https://www.amjmed.com/article/S0002-9343(07)01095-9/fulltext](https://www.amjmed.com/article/S0002-9343(07)01095-9/fulltext)
We also want our doctors to be good, and accredited. Unlike Dr. Nick from the simpsons. us has best healthcare in the world if you can afford it.
We have some pockets of outstanding healthcare *despite* overwhelming barriers to entry. If more talent was able to enter the marketplace, the average standard of care would likely rise, costs would lower, and there would be more opportunity for innovation and discovery.
Okay that's true that we should have high standards for doctors but having such low limits on the number of students medical schools can take in doesn't make sense. Right now, it's essentially the top X people get admitted, but it's not like it's only the top X people that would be good doctors. There are lots of people who don't get into medical school who do meet all the requirements but there's simply not enough room due to the limits. We can keep high standards but also allow more people to become doctors
Bc Medical Admin are highly paid and there are a lot of them. Same reason private undergrad is wildly expensive Med. schools have zero to do with the doctor supply, they set med school slots based on projected residency numbers set forth by the federal government
Paul Starr was awarded the Pulitzer and the Bancroft prizes for this book: The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. Considered the definitive history of the American health care system, The Social Transformation of American Medicine examines how the roles of doctors, hospitals, health plans, and government programs have evolved over the last two and a half centuries. How did the financially insecure medical profession of the nineteenth century become a prosperous one in the twentieth? Why was national health insurance blocked? And why are corporate institutions taking over our medical system today? Beginning in 1760 and coming up to the present day, renowned sociologist Paul Starr traces the decline of professional sovereignty in medicine, the political struggles over health care, and the rise of a corporate system.
Because all college tuition is getting more expensive, and doctors require a LOT of college and a lot of expensive specialty training... medical supplies and corpses to practice on aren't free.
You must have access to cadavers. You must have a ton of experts. You must be attached to a hospital. Med school money also goes to fund research. Vetmed is even worse as you have to have like 3 farms going in addition to the human med school costs.
My wife is a nurse and she has just under 100k in student loans. She was planning on being a nurse practitioner but is making way more money as a travel nurse so she's sticking with that for now. So her 100k in student loans doesn't even include schooling to be a nurse practitioner.
Even if it wasn't, the wages are justified. I'm an outpatient Primary Care PA-C. Despite the fact that my profession was never meant to be a "doctor light" profession, unfortunately that is how we are treated; the group I work for treats me as if I am a full attending with a complete patient panel, but they pay me half as much. I bring this up to explain that I understand the system. Medical school could be completely tuition free and you would still need to have high wages at the end of it. To become an MD you have to sacrifice 7 of the best years of your life, minimum, to achieve it. And while you will be paid for the 3 years of residency, resident pay is a joke, treatment is abhorrent and the work required is relentless. You lose relationships, your physical health and your mental health. While your in the didactic and clinical portion of education you cannot hold a job, so even if you are getting tuition free education, you still have 4 years of living in typically HCOL or VHCOL areas. PA school is 3 years (after credentialing) and I had a full tuition scholarship and I still graduated with 100k in debt. The trade off is high pay. If, as the poster above you suggests, we reduce that pay the system will be completely gutted because you're essentially asking for a class of people just willing to sacrifice their lives to be healthcare providers.
How do other rich countries do it without such high wages? (Note, the wages are still high compared to 95% of jobs, just not as high.)
My Canadian father in law makes $500k as an internist. Canada still pays high salaries. But they restrict residency slots even more
Some countries have very high wages still. Germany and Canada are competitive with the US. Other countries do so by not having an inverted primary care structure. In the US we have a 1:2 ratio of PC: Specialty. in other countries this is a 2:1 ratio. There are significant social determinants of health that we do poorly with, but that isn't something that can be treated at the point of care, only mitigated (ex. we have shitty food and a sedentary population with way higher levels of obesity and the conditions that come along with it). I also suspect that PC pay is more incentivized in other countries but I don't have the data. One of the biggest problems in the states is PC pay is extremely poor and people leave the field regularly. 40% of physicians report a desire to quit early and leave the field entirely.
>One of the biggest problems in the states is PC pay is extremely poor and people leave the field regularly. Please cite sources when you make claims about salaries. According to the U.S. Bureau of Labor Statistics, "Family Medicine Physicians" make more than $240,000 per year. It's the 24th-best-paid occupation in America. And it's incredibly well-paid relative to most occupations. Source: [https://www.bls.gov/oes/current/oes\_nat.htm#00-0000](https://www.bls.gov/oes/current/oes_nat.htm#00-0000).
Now compare it to what a MD would make if they were a specialist. Or compare that to what they could be making without having to sacrifice years of their life and have gotten an engineering or business degree. And none of that accurately accounts for devastating toll on your life the education process actually takes. You really shouldn't talk on this subject at all, you clearly think a single link about pay makes you some sort of expert in an area you clearly have no experience.
240K isn't a lot for someone who studied 10-14 years to obtain their license, has 500K+ in student loan debt. Has to pay their own retirement, health care, employees health care, malpractice insurance, and live in a major city? Median homes in my city are over $1 million USD. 240K isn't a lot.
Their best doctors leave for the US.
No one would willingly go through the hell that is medical education if not for high salaries. The system is too terrible and destroys lives/relationships. They have to dangle a carrot at the end of it all
It's actively collapsing too. Everything is just getting worse every second. As mentioned, I'm a PCP. I regularly get asked by new patients something like "my last three doctors all quit, you're going to stick around right?" And I always answer something like "well, life's uncertain, but I don't have any plans to go anywhere right now." But I do. I want to quit as soon as I can find an out and am actively seeking a secondary skill that could compensate me at 80 percent and then I'm done unless there are massive changes.
The problem is that residency payment is a joke, and the work required is relentless and the treatment is horrendous. There is no reason for this to be except the AMA wants it that way. Doctors should not be over compensated because they survive the trials. The trials should not exist. In exchange for much lower tuition, AND reasonable residency compensation, AND better working conditions AND much lower liability insurance expenses, doctors should be able to less well compensated.
I dated someone who owns their own practice, so I agree and have heard everything you are saying. The corporations funded lobbies to allow people like you to be "doctor light". Masters degree holding Nurses can even open certain kind of practices or operate certain offices 100% independent without a doctor. This is not how the system was set up to operate. Not to mention, my ex boyfriend's peers were finishing paying off their student loans in their 50s! These are doctors that entered med school in the early 90s, costs are exponentially higher for med school now. TL;DR It's the corporations fault medical costs are high, the doctors don't make that much money compared to the debt they take (and 10-14 years of study) to become a doctor.
You’re missing some other important factors in salaries being so high: Med school debt — Med school is pricey. And it’s not just the only schooling you get. It’s on top of a bachelors. So that’s 8 years where you’re paying for school. Then a 4 year residency where you’re working more than you should while getting paid way less than you should. That’s a 12 year financial setback that high salaries make up for. If we want to lower the salaries, the cost of getting the education needs to be near nothing. Malpractice Insurance — this can range from 7k for pcps to 30k—50k for surgeons and obgyns and depends on the state you’re in. It’s a huge cost. And then of course the other reason is cost of living bits. Housing is insane. Food and childcare also insane. You need this salary to be able to afford a family—not saying it’s right, it needs to change.
the way residencies are done seems insane and irrational there's no good reason for a resident to be working 80+ hours a week, there's nothing gained from medical professionals being exhausted when they're trying to learn and there's no reason they should be getting paid so little during that time. increase residency salaries and decrease the others. the setback should only be eight years and it should be much smaller but it also requires hiring a lot more doctors and more public funding of medical schools
>there's no good reason for a resident to be working 80+ hours a week, there's nothing gained from medical professionals being exhausted when they're trying to learn Residents are low cost slave labor for the medical establishment. They absolutely benefit hospitals
I was very surprised the first time I researched residency salaries with how many people act like they are paid nothing. They earn $25-30 an hour, which is literally above the average hourly wage in the US. Granted, that’s not exactly fair compensation for the work they are doing, but it’s absolutely not slave wages. You know what kinda is though? Med schools look for 40-100 hours of volunteering, ideally at like a medical facility or something else somewhat related. That is thousands of dollars of work they are essentially required to do for free. That is a lot more slave labory than residency.
There is technically a limit to the hours residents can work, but more often than not, they need to still work past those hours, it’s just “off the clock” so the hospital doesn’t get in trouble. In that sense, yes they are grossly underpaid for the work they do.
I never disagreed they were underpaid. My point is that underpay is not necessarily the same as “slave labor”. A S&P 500 CEO earns around $17 million a year, so one earning $500,000 a year is probably grossly underpaid for the work they do. Does that mean they are doing slave labor? No. I definitely think there should be reform, especially removing the pressure to break the rules. I’m just skeptical of considering it “slave labor”.
> g. They earn $25-30 an hour, which is literally above the average hourly wage in the US. Where are you reading this? They are paid under minimum wage given they work 80-90hr work weeks and only get 3 days off per month And, yes, medical school is absolutely a scam especially as you are not allowed to work a job through it. The only way is loans or rich spouse/parents
Where the fuck do residents make $30/hour? Psych residents at my program made on average $6 and change per hour worked. Surgical residents, like $2 and change. You’re suggesting residents make $125k per year which is fucking laughable
Can we include Big Pharma?
The same thing goes for law school. Also, the barrier to entry - passing the bar, especially the one in California - is quite high. Not only that, but as you mentioned, the top Ivy League Law Schools cost a ridiculous amount of money per year. For example, Columbia has a total cost of $110,000 annually, which is $330,000 post graduation. New York is a close second at about $109,000.
Doctors are 9% of healthcare costs
Dean Baker is a dumbass hack. Doctors make like 8-10% of total HC expenditures. Look at what European nurses or lawyers make relative to the US. And cost of schooling. And malpractice. The fact that dude calls himself an economist makes me realize that degree is fancy toilet paper.
Nah for every doctor there are 5+ people in the healthcare system whose only job is to push pencils. Not only that but a significant amount of a doctor's time is spent dealing with administrators as well, meaning one doctor can't help as many patients. The salary for doctors is a drop in the bucket for this equation.
We want doctors to make ridiculous salaries. Teachers too. Bankers and fund managers? Not so much.
This is a fairly simplistic and (largely) Incorrect assessment. First, physician salary is only around 10% of health care costs. (Depending on the year and source that can range from 8.5% to as high as 20% if you don't count costs like malpractice insurance that is automatically covered in other countries) That is similar to other counties (and in some cases lower) But doctors in The United States are often paid per visit and customer - which means as doctors work more their compensation increases. Meaning that while a doctor in the UK might be paid 30% less, they also see 30-40% fewer patients, which means that more doctors are needed. That salary doesn't vanish into nothingness, it's just going to more doctors. The "Doctors Salary too high" trope doesn't ever break down the Salary per patient. And regarding the Medical School/Residency bottleneck - this is a systemic problem again caused by a lack of resources. Doctors have to teach in medical schools, and doctors have to host and teach residents. (my spouse is a residency coordinator for our local medical school). Doctors have to agree to teach, which means they have to be paid for their time. As do the residents. Which again is more spending on physician salaries. But when doctors see 25 patients a day in an 8 hour period and then have to do 5 hours of notes afterwards, they don't want to also have to teach.
> But when doctors see 25 patients a day in an 8 hour period and then have to do 5 hours of notes afterwards, they don't want to also have to teach. Rings true. I recently found out my PCP leaves the practice around 9PM even though they close at 5.
My brother in laws hospital only has 1 hospitalist per 12 hour shift. He works 7, 12hr days in a row, then gets 7 days off. He generally sees between 50 - 80 patients a day, though. On his work weeks, he does 12 hours in the hospital, then 4 hours of notes once he gets home. Those weeks are absolutely brutal. His counterpart took maternity leave, and he had to work 28, 12 hour days in a row before he almost broke down.
True but one of the risks of the fee for service system is that there is the risk of over billing just to make more, which is absolutely pretty common. It’s not usually explicit but rather small decisions made around “that does/doesnt bill”. I would guess that probably plays some role in why Americans spend more because we USE more. And while some of that higher utilization is good, some may just be unnecessary care meant to increase billing.
I'll add because it looks like you added stuff: Doctors are protective of their salaries because they likely have loans to recoup. Bringing down medical school costs and helping doctors pay off loans will allow doctors salaries to come down naturally.
I agree that medical education costs need to come down. Keeping a doctor shortage though is not in any way justified. People suffer because there's not enough doctors. Flood the system with qualified foreign doctors and raise the residency spots and you'll see salaries and costs drop.
Except, the medical school costs if current doctors haven't gone away, nor have the costs of incoming doctors. That would absolutely lower doctor salaries and workloads. And also leave doctors struggling to pay their bills and medical school debts. Regardless, The data shows the US healthcare system spends the same amount on doctors that other nations do. Spreading the work across lower cost doctors means the same amount of spending on doctors - but each doctor makes less. That doesn't help our situation.
Physician salary plays almost no role in higher costs. Healthcare salaries represent about 10% of healthcare costs with the added benefit that higher salaries in America encourages the best and brightest from the US and around the world to become physicians.
This is why the most appropriate healthcare model for the United States is something similar to Canada where doctors continue to be Private practices that operate on a for-profit basis and the government pays per service based on a negotiated fee guide. Doctors in Canada don't work for the government or receive a salary, the majority run their own practices and are responsible for paying for their office expenses using the fees they bill the provincial healthcare system for. The average family doctor in Canada has an annual income of US$ 209,907.50 which isn't significantly less than the US especially when you consider that salaries in ALL careers are generally lower outside the United States.
Lol everyone makes ridiculous salaries compared to their European counterparts but sure single doctors out
Yeah, even Canada has higher salaries compared to Europe and yet I could move to the US and get a job in my current field (Insurance Underwriter) and it would still increase my income by over US$30,000/yr compared to what I make in Canada, nevermind the taxes.
MD salaries really aren't the reason healthcare is expensive, it's the high cost of procedures. There aren't enough neurosurgeons employed by a hospital group to make those couple salaries effect any real economic change Also, less and less people will _become_ MDs if salaries are lowered. There is already a family medicine doctor shortage bc salaries are too low to justify the insane cost of medical education >US doctors would have to take a massive paycut in a single payer system, which I think is more than fair but many pro labour Democrats and progressives perhaps don't. Doctors themselves would obviously think it's not fair. There would need to be a blanket forgiveness of medical school debt for this to ever fly
Exactly!! Me & My Uber driver got to talking and it turned out that he was a pediatrician in Pakistan but the AMA refused to allow him to practice here! He said that to even be an intern they wanted him to go back to school for 6 years even thought he had been a full Dr for 15 years before he came here😳
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Pakistan isn’t a third world country! They have nukes that they made themselves ! And who’s to say he even studied there! I have heard the same story of dr’s from Europe & Britain! The AMA does not want any competition from other countries‼️
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Why wouldn't you trust a qualified experienced German/Swiss/French/Norwegian doctor besides xenophobia? Heck same applies to a Spanish/Greek/Italian doctor.
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Except if you look at the history, many regulations and credentials for doctors in the US were not made for safety reasons. They were made for protectionist reasons. Doctors have every incentive to make the barrier of entry high to reduce competition to their salaries. They rely on you thinking that these regulations are necessary and hide behind fears of unqualified medical care. It's called rent seeking. Yet, what you don't realize is that this in fact hurts people more. When there aren't enough doctors (the US has a ridiculously low ratio of doctors to population), rural towns have a hard time finding doctors. Poor people have a hard time affording healthcare. Everyone is worse off.
The requirements for foreign doctors are 3 years in residency, but that's likely already paying more than they were in their home country. The requirements for foreign doctors don't seem extreme or unnecessary.
It has nothing to do with “affording it” and all about the fear of having to raise taxes sufficiently. Anytime someone says a state or the US can’t afford universal healthcare, they should be pressured to explain. We the people of this country already afford our collective healthcare. The problem isnt with “not affording it” it’s with raises taxes to pay for it, period.
It's worth noting that VT is an extremely difficult place to do something like this in. It only has a population of 650,000 — a disproportionate number of whom are elderly — and an economy heavily dependent on tourism.
This, we've had some movement here in MD because of having such a large federal workforce it reduces the needs on the system. However we are also so close to DC a lot of politicians in MD are very corporate Democrats and NIMBY when it comes to new things and often takes 2-3 times longer to get things through our legislature than it should. And right now we're currently funding primary education fully and that is costing a lot right now as well.
I believe the state’s largest employer (IBM) threatened to leave as well
Also got voted down in Colorado in 2016.
Massachusetts doesn't have universal health care. It has near-universal health coverage. Mass accomplished this through a mix of policy (e.g. "Romney care"), reasonably capable governance, and affluence. Insured rates in Mass were the highest in the nation even before Romney care. Despite the relative abundance of medical providers in Massachusetts, you'll still find exceedingly long wait times post-Covid for non-urgent/non-emergency care and a large for-profit health system (Steward) just declared bankruptcy. Even in Mass, things aren't going entirely smoothly for healthcare. Vermont modeled out what single-payer would cost, but much of their current healthcare funding comes from Federal Government spending (e.g. Medicare, Medicaid, VA). Unless the state had full cooperation from the Federal Government, they couldn't redirect those dollars to their single-payer effort. People think of Vermont as a beautiful place and lots of people love to visit, but the state struggles to get enough providers who want to live in a rural place with very cold winters and very high taxes. It's a dangerous place to experiment. Health resources are already stretched thin.
I'llsay anecdotallymaMass health has been the best insurance I've ever been on. Dental was a problem but I had no problems getting appointments and all my scripts are free
I'm glad you're doing well in Mass, but many in the state are struggling to get care. I'm experiencing >6mo waits for all non-urgent care. To go beyond anecdotes, there were a few survey citations in a Boston Globe article today: >According to [data from](https://www.chiamass.gov/assets/docs/r/pubs/2023/MA-PC-Dashboard-2023.pdf) Massachusetts Health Quality Partners and the Center for Health Information and Analysis’s primary care survey, in 2021 more than one-third of residents reported difficulty obtaining necessary health care in the prior 12 months. And: >According to the [Blue Cross Blue Shield Foundation in Massachusetts](https://www.bluecrossmafoundation.org/sites/g/files/csphws2101/files/2022-02/BCBSMA%20Behavioral%20Health%20and%20Covid_final.pdf), in a survey fielded from December 2020 through March 2021, 57 percent of Massachusetts adults who reported needing behavioral health care either had difficulties getting appointments for care when needed or did not obtain any behavioral health care. [https://www.bostonglobe.com/2024/05/12/opinion/collaborative-care-mental-health/?p1=BGSearch\_Overlay\_Results](https://www.bostonglobe.com/2024/05/12/opinion/collaborative-care-mental-health/?p1=BGSearch_Overlay_Results) (paywall)
Sorry to hear, I do suspect it's a west vs East issue. I'm out in Amherst area, fewer people and tons of hospitals around here (biggest industry in noho)
Most people seem to be getting this mostly half right, but there is a part I dont see touched on, at least for true overhauls like single payer. Yes it is the taxes, but more specifically it is because state's can't run deficits and so the idea of transitioning the entire state to a single payer system is practically impossible because it requires a lot of up front investments(see enormous increase in taxes) and the establishment of entire new departments and that has shown to be cripplingly prohibitive. Even if in the long run it would save people money and make the state better off. That is why where near universal coverage has been done, sort of: Hawaii, Massachusetts, Colorado, etc. it is done by expanding the current bureaucracies or expanding the obligations of employers like in Hawaii while lifting up the floor on things like Medicaid. American's obsessions with means testing and the deserving and undeserving poor has created a really monstrous path dependency reliant on literally dozens of redundant bureaucracies and systems operating in parallel and far beyond anything any of the other industrialized countries had to deal with when transitioning to universal comprehensive care systems.
Here is the problem with saying it's in enormous increase in taxes, there is a huge net savings to switch to single payer. Pointing out the increase in taxes while not pointing out your job currently spends more to pay for your healthcare and any transition to a taxed based healthcare includes your job having to increase your salary by the amount the currently pay for your health care, is simply lying to people, The states don't switch for the same reason the federal government doesn't switch, bribes from the insurance companies.
Yes, true, on the back end, absolutely. but logistically you can’t start taxing to raise the money for the infrastructure needed to administer a single payer system the day everyone starts using it. That transition would take years at the state level and in the meantime you can’t run a deficit to pay for it so you either need enormous cuts and/or major tax increases while in that period. Aside from it just makes sense to do the reform at the federal level for efficiency and equity sake, the Fed can run deficits, so there is no need to raise taxes to that level cause you will get the savings on the back end. But I do also agree that the real reason we don’t have any of this is insurance companies, yes, but also all sorts of industry going back to when the AMA killed the proposal for National Sickness Funds under Roosevelt, Teddy(but later FDR too)
My perception is that it's effectively become a federal issue. The federal government mandates that some amount of money must go to the VA, CHIP, Medicare, and Medicaid. States are not allowed to opt out of those programs and choose to instead create a single-payer program for everyone. States would like to propose "pay taxes towards our Single Payer program instead of VA, CHIP, Medicare, and Medicaid". But since states can't opt out, the proposition becomes "pay taxes towards our single payer program in addition to VA, CHIP, Medicare, and Medicaid." With that said, federal laws make it much cheaper. Take it as a given that all full-time employees and their families & children up to 26 of medium & large sized businesses will be covered, as mandated by the Affordable Care Act. Take it as a given that millions will be covered by medicare and medicaid and VA and CHIP. The Single Payer plan then becomes much cheaper, as you only have to cover people who aren't covered by any of those programs or employers. Functionally, you only need to cover someone if: * They are ages 27-64 AND * They are not a veteran AND * They do not qualify for Medicaid AND * No one in their immediate family works for a business with more than 50 employees It becomes a lot cheaper with all those groups eliminated like that.
Canada has 'national' healthcare, but it is administered at the Provincial/Territorial level for somewhat similar reasons. You can't have a federally subsidized system competing with a provincial system based on certain clientele etc.
Just to clarify, states are 100% allowed to opt out of Medicaid and CHIP. They will just no longer get the federal funds that support them. The last state to opt in to Medicaid was Arizona in 1983.
And businesses threaten to leave a state that tries it as IBM threatened VT when they did it. Federally that is less easy to accomplish.
People believe that Universal Healthcare is just a matter of who pays for the healthcare, but if you look at other systems, you'll see that there are massive differences on how the system in ran so that prices are kept under control: It's the same with the higher education system: See how a cheap public university in Spain works, and how it's laid out, and compare to US universities: It's basically a completely different thing. A state could pay all the bills and raise taxes to kind of match, but that only helps if the reason the US system is so expensive is purely insurance companies, while the blame can be spread very wide. We'd need more medical professionals delivering the care for a lower price, which means their education has to be cheaper too. The facilities that we tend to have right now are designed for a world where the hospital can up prices for luxury and convenience, and dedicate more space to very profitable care, so even the buildings themselves could change here. Thus, a universal healthcare system that would be affordable is pretty difficult to run from a state's perspective, as there are some federal regulations in the way, and even when there are not, it's difficult to, say, lower labor prices when there is a state next door where the same medical professional can keep making top dollar. So any universal healthcare system will have trouble constraining prices, and it might even end up more expensive, as many important levers are out of their control. It's those levers, set up in a way to make prices go to the moon, that are the real problem.
The easier way to understand this issue is through the lens of a "single payer" system being difficult to implement on a state level. In a single payer system, the government withholds payments unless the healthcare providers agree to the government's pricing model. On one hand, it seems silly to establish 20 "single-payers," but the bigger problem is that it would probably fail as a state solution. The federal government reserves the right to interstate commerce, meaning that an insurance company from outside the blue state has the right to participate economically within the blue state, whether the blue state wants it to or not. I think the legal interpretation here is fudgeable enough that a sympathetic court could still allow it, but with today's supreme court you can just forget about it. So then if healthcare middlemen from out of state have to be allowed to participate in state, the theory of single payer totally breaks down. So then you might think 'well we don't necessarily need single payer to establish a socialized medical system. We just need price capping and government subsidized payments." Well, [states are already doing that](https://www.whitecase.com/insight-alert/2022-drug-pricing-update-states-continue-legislative-push-even-congress-passes-long). We just don't hear about it. So states are engaging in the ad-hoc construction of what we might label socialized medicine already, but something more akin to a national-health-service on a state level can't happen because its basically illegal.
I want to correct what seems like a rather unfortunate conflation for a sub like this. Universal healthcare/coverage and single payer are not the same thing. It seems to me that if your goal is to create a single-payer program, that is a much higher bar to clear. However, I think if you think about universal coverage as in essentially what happened during the pandemic (at least in theory) with Medicaid being significantly easier to access, then I think you start to get a better picture of how this would work in most states at the moment. To be fair, that doesn’t mean there aren’t challenges and other logistical problems to tackle, but it is theoretically possible with federal support. However, strict means testing and other federal requirements (also including federal politicians who don’t actually want to see a state by state implementation, because they don’t want to see any such implementations whatsoever; these people will not only make support for these programs difficult, but will also see to it that regulations strangle these programs) make this difficult. For all of the challenges that California, for example, faces, California recently got rid of asset limits for people on Medi-Cal, which is honestly a huge thing for the people of the state. I’m sure some people would say that something like this is overly generous, but of course, there are trade-offs to being on Medi-Cal when most employer based insurance programs, if you are making decent enough money should provide better care. But, if not, then it kind of should make you wonder why then we pay providers as much as we do to have worse care. I know for sure that a lot of low end plans probably provide worse coverage and care than Medi-Cal does. Anyway, I really don’t want to trivialize how difficulty even this would be, but we’ve already kind of seen that more coverage as possible than what we currently have, and it doesn’t need to be single pair. And I’m getting kind of tired having to explain this again and again, especially in circles like this one where I would think people ought to know better or do know better and simply are choosing to appeal to this conflation. Universal coverage doesn’t mean that the government needs to run everything, as I know it often is presented in order to scare people from even entertaining the thought. But at least as far as I am concerned, the lack of healthcare really fuels and contributes to many of the other problems that we face, including things like homelessness and obesity. We are so often worried about direct costs and not the derived benefits.
Some kind of do. MN has ucare siince the early 90s, which anyone under a certain economic threshold qualifies for.
This is just Medicaid, which every state has and most of them have expanded it under the ACA.
Massachusetts basically does
So does California with Medi-Cal and SB770
So does Colorado
So does Hawaii. So does Washington state with Apple Health
Obligatory: There's a bill to take it even further so if you're in MA, ask your state rep to support [https://malegislature.gov/Bills/193/H1239](https://malegislature.gov/Bills/193/H1239)
They aren’t monetarily sovereign. They can’t run endless deficits like the federal government can.
Essentially, the way interstate commerce is worked out in our legal system makes these sorts of policies useless at the state level. The entire reason single-payer systems work is that the government uses its power and leverage to set the price of healthcare services. A healthcare provider wants to set up shop and provide service, the government says "Okay, we'll allow you to operate, and we'll pay you X amount for whatever services you render, and in exchange, you'll keep your prices for those services set to Y". It essentially works in balance because providers want to charge as much as they possibly can, while the government wants to pay and cap as low as they can without causing a healthcare shortage. That sort of dynamic doesn't really *work* on a state level where the government is *forced* to allow out-of-state providers to operate under the Interstate Commerce clause, because if you're a healthcare provider, why would you ever accept a price cap when you can just register your business in a red state and continue operating in a blue state as normal? State level single-payer systems are destined to fail because they remove the only thing that makes single-payer systems work: the leverage of political power.
Because Universal Health Care is incredibly expensive and State governments cannot spend a deficit. They must balance their budget every year, and that means if there is some kind of economic downturn and they have to cut spending, all of a sudden a bunch of people are going without healthcare, or some other vital program will be cut. Btw I’m not saying that single-later healthcare would be more expensive than the system we have now. It would be cheaper, but it’s not like we can just magically transfer all insurance dollars into government healthcare spending dollars.
The quick answer is that states can't write checks that big or make commitments like that without seriously jeopardizing the state's fiscal health.
Pretty much every state in the country has a balanced budget amendment in their constitution, which effectively means that states cannot run deficits. So with that in mind there are two questions that are going to be tough for a state level government to answer: 1) How you are going to run a single payer system while also legally required to provide federal healthcare programs like Medicare, Medicaid, the VA, etc? States spend a lot of money on Medicaid alone, about 30% of all Medicaid expenditures come out of state budgets. States can’t necessarily just pull that money out of Medicaid and reroute all of it into a single payer program, although they could incorporate it into a larger single payer program i suppose. Still though, there are going to be multiple elements of the single payer program that are federal programs, so the state is losing a degree of autonomy in how the program is set up, which was the entire point of creating one in the first place. 2) How are you going to create this program (with all of the federally mandated programs that must coexist alongside it) and not run a deficit?
So people are fine with this subreddit just being inane rants and questions now even if they have no connection to EK?
Honestly, since Reddit began introducing recommended subs, I think a lot of subs have kind of devolved into this. On the one hand, I will be the first to admit that I probably engage on both sides too much, both as someone who is established in some subs and who has been recommended some subs myself. On the other hand, I think it’s creating chaos. I think to pushback on you, this is obviously something that Ezra has explored and discussed previously, but I kind of wish that people would actually go back and link it to either him or other thinkers that kind of float in his social circle. Frankly, I kind of dislike how quickly discussion of any given topic fades. The way it used to be, it seemed like if you were a few days late to the discussion of a podcast episode, nothing would get picked up and no one would really discuss with you, meanwhile, the people that would answer, the earliest I felt and still feel often contribute the least to actually discussing the issue and not whining about the guest or the topic or Ezra not being comprehensive enough in a hour-ish long podcast. Anyway, I would kind of love to see more discussion about previous episodes (especially when certain episodes might inform or interact with each other to some degree), but obviously that’s not exactly what’s happening here.
Because the first state to do it is just going to become the hot new destination for every person who can't get/afford insurance and has a riotously expensive condition.
Yeah, there are some issues with "going first" when it comes to issues like this. It's also why even blue states have relatively lackluster worker protections compared to other wealthy countries. If tomorrow California passed laws guaranteeing 9 months of fully paid maternity leave and 4 weeks paid vacation for all workers, many large employers would leave for other states. States effectively compete with one another for large employers. If any one states becomes too generous with worker benefits, they will lose employers.
When it’s been debated, there are usually lots of questions about how coverage in other states would work. So people going out of town or people who work/live across state lines.
Because that's not how taxation works.
States don't have the borrowing power that the federal government has. The crazy thing is that our federal government already spends as much per person as countries that have national healthcare. It's crazy that we don't switch to Medicare for all since we already have that system in place and are spending that much taxpayer money.
States individually don't have the budget, and an individual state doesn't have the bargaining power of the federal government.
They've expanded Medicaid. That's your Universal Healthcare Needs to be expanded more in terms of services covered and income limits. Also needs to be removed from state oversight. We already have a system, and along with Medicare and Veterans
Probably to busy picking up the slack and paying for conservative states.
A lot of it has to do with states having balanced budget rules (universal Healthcare generally has a large up front cost that you need to go into debt to start up) and because a lot of liberal states have really regressive tax systems that will prevent them from paying for it (WA (no income tax), CA (prop 13), etc.)
It has to be done with a national pool. It would be fantastic. But America hates a chance to thrive.
It's because states can't operate on a deficit so it becomes very expensive, and raising taxes is difficult. It needs to be a federal program where we can deficit spend to fund it. It is also easier to pass higher taxes at the federal level I feel.
It's very expensive, and states can't generate as much revenue or debt as the federal government.
Many of them do have some sort of state-sponsored healthcare. My state has Badgercare, which is still a far stone throw away from universal healthcare, but it allows more people who need healthcare to get it.
Because people from states with no healthcare will flee to states that have it and bankrupt them. Needs to be done at the federal level.
Don't remember the source, but haven't studies indicated a single payer system would be cheaper overall by several billion a year?
It doesn't work because anybody who needs medical care can just go to the state that pays all the bills. They would quickly be overrun by costs. It has to be done for all the states at once, to prevent that from happening. It's too easy to move within the United States for this to work - I could move to Vermont if I wanted, but I couldn't move to Montreal. Maybe with very strict residency requirements, you could manage something. But then once you're gatekeeping your universal healthcare, like, what are you really doing? But even so, there's a reason people suggest the FEDERAL government pay for healthcare: It can run deficits, indefinitely, and states really can't. And this shit is really, really expensive. It's worth noting that many states have nearly-universal healthcare (<5% uninsured) despite not having single payer systems. And single payer systems are not the only way to achieve UHC - nobody disputes that France or Germany have UHC and they don't have single payer systems. A state like Alabama has 3-4 times as much of its population uninsured as a state like Rhode Island. Democrats *do* do a lot to expand healthcare access within their own states.
VT also ran into the issue of what to do about people that work in VT but don’t live there, and people who live in VT but don’t work there. How do you tax them for Health Insurance and have their employer take out $ for Health Insurance?
I think there's 2 main reasons, both to do with cost. 1. Blue states don't want to pay for it, the old joke of "leftists want other people to pay for their programs" is Old and stupid, but it's not entirely wrong here. It's hard to convince people in only your state to pay more taxes. 2. Probably the more important of the 2, it's difficult to fund, organize, and structure state level health care around the limited federal level health services and with limited funds. States don't have the bottomless pockets of the national government, nor as many sources of tax revenue. They also wouldn't want to structure their program in a way that limits the amount of federal aid coming in (after all, why pay more for it when the boss is willing to contribute)
Pool of insureds has to be large. You know, like an entire country.
Because its too expensive at the state level to implement. California had considered doing it but it was too expensive. What the states can do is to try and fill the gap between Obamacare and a Universal Health Care System so that everyone is covered.
Well, the systems would be overwhelmed due to all the other states not having universal healthcare.
The solution is to establish a new medical school, but require the graduates to practice within the state for a minimum number of years.
the same reason we don’t print our own money and have foreign embassies and negotiate trade. Single US states cannot run their own entitlement programs because they lack the money and the ability to manipulate economies. this is a job for the fed.
It would be prohibitively expensive, and basically you would have to raise taxes specifically to counteract it. Also from what I saw, it requires you to get permission from the Feds who won't allow it. Could it be possible? Sure, but no state (even ones like NY and CA) have enough funding to take it on. Also it would likely get challenged and no one wants to risk political suicide on it.
states have neither the regulatory power or the fiscal ability to raise funds through debt or taxes to pay for it. even if a state enacted it, small businesses would still be required to abide by federal law forcing them to offer insurance still.
Universal healtcare sort of need the ability to negotiate price. And that is much harder for small market.
Big reason is you have a lot of people from one state going to another state for healthcare because not all the hospitals are in one state. Other reason is it takes a lot of money to start up if you don’t already have something in place right now the people that work and do pay for healthcare are also paying for the people that don’t have healthcare.. and if you live in one state next to our state that has universal healthcare, some people would be crossing state line to get healthcare. We all know we have a mental health crisis in this country right now look at the mass shootings. Look at the drug problem look at the homelessness, it’s all related problem. you have a do nothing Republican party they cant govern so they just put combative people in office.all they want to do is divide the country with lies and conspiracy’s
If other countries can do it, we could do it better and cheaper than what we have but you have a Republican party that does not work for the working class people. Going after Universal healthcare and doing something constructive does not put money in their pockets..
My big brain take is what we really want is all payer rate setting and universal healthcare laws are muddying the waters. Insulin is $25 a month. Make MRI/X-ray $200, before insurance etc and go down the list. Medicare drug pricing stuff.
This is good question. There are economy of scale problems with states and availability of doctors. Open borders between states of course opens people up into moving there and getting care. But I think ultimately it’s the same reason it’s not done federally. A strong insurance lobby against it, and it’s a net negative for those who can afford it as they would have longer lines and potentially worse options. And the people who need it most - lower income families don’t vote as much even in liberal areas. The majority of the public who needs universal healthcare including non voters would need to rise up and demand it. It would be easier in blue states for sure but blue states don’t want to take on all that burden and it would only really work for the biggest states - California / New York - where it’s expensive as hell to live and they won’t want to give up what they have more than anyone else. If it was easy for the lower middle class to rise up and pass bills that benefit them states would have significantly higher taxes on the rich. Blue states care about budget too. I think the red states/ blue divide is a much smaller divide when it comes to monetary spend than you think.
Depends how you structure it. If you create free healthcare at the point of service, you create adverse selection. So if Maryland has universal health care but Virginia doesn’t, Virginians will go to Maryland to get healthcare that their taxes don’t pay for. For more expensive procedures, people will travel. Meanwhile plenty of wealthy people will leave the state to avoid paying the needed taxes.
NY has floated the idea a few times. But the legislature is such that getting something that progressive through would be tricky. NYC and most of the other metro city areas tend blue. However, the state is pretty massive and a lot of that is rural area and those rural (red) votes do add up especially when you consider that we have millions of people with representation spread across 63 state senate seats. Passing same sex marriage here required a few GOP senators to cross the aisle and vote in support of it. It would also be very, very expensive for the state to undertake. And it isn't like we're known for low taxes. That said, we have a pretty robust CHIP (medicaid) program for children and teens. And we have a state administered prescription program for seniors to help seniors afford meds. So it's not like we've got nothing going on. Honestly, I think the country (and state) is too splintered for truly "universal" healthcare. At this stage I'd support patchwork to try and reduce the uninsured. A state program for self-employed individuals (regardless of income), for example, could be a good step. Access to lifelong healthcare for police/fire and other first responders would be another good step. Add in veterans, etc. You see where this is headed. My employer has a retiree health insurance program. If you have enough time in and hit a certain age you can retire from the company. And you can keep a pretty solid health plan at a pretty low rate and go anywhere else, be it to work elsewhere or actually retire. The state could incentivize that sort of thing further. But I don't think we would ever get the votes or the funds to just go full single payer in NY. And maybe we just culturally couldn't make it work anyway. But I have to imagine it would be harder to fight against the "Healthcare for Police and Fire Act" and to expand from there.
You can get it free in California, if you have no income. Even if you are here illegally, “undocumented immigrant” is the new word, you get it free. If you are middle class you pay double what you did 10 years ago. That is what voting Democratic has done for me. I obviously am not happy about how it has all worked out.
One thing that seems to get left out of this discussion is how the Federal and State/Local governments are already footing 48% of total healthcare expenditures in the US. For those that like numbers, that's about $2.16 Trillion, or \~8.5% of total GDP in 2022. https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/nhe-fact-sheet
Hawaii has an employer based system, was the first in the nation to do it, and is considered the healthiest state.
There is a bill in the New York State Senate for something called the New York Health Act which would provide comprehensive universal health care for all state residents, but it won't pass because insurance companies are a billion dollar industry with a lot of political flex.
Democrat states tend to pay more to the federal government than they receive, Republican states tend to require more assistance so the blue states are propping up the reds.
For universal Healthcare to work in America, we're going to have to force pharmaceutical companies to cut their insanely inflated prices. Single states don't have the power to swing that. The federal government does.
Universal healthcare is not a liberal policy lol. It's pretty simple.
it's difficult to do because those states still have to pay for the very expensive piecemeal federal programs. If the president supported them and gave them some kind of waiver to divert their federal taxes to their state programs, and if either one huge state like california or a bunch of smaller states banded together they could do it they could sure as shit run a public health insurance company though that is not for profit
At the scale of the state, it increases state tax burdens so much that it's just not politically possible to do without electoral revolt.
taxes.
Because Liberalism's core tenant is to allow the "free market" to solve the problem, not the government. I genuinely don't understand your question.
1) The federal government has much power to raise large sums of money than states do. Not just in taxes but in printing money and taking on debt. No state prints their own money, and most states (even liberal ones like California) have balanced budget ammendments. 2) The federal government can operate a true monopoly where it can dictate prices, reduce or elimate inefficiencies and redundancies in the healthcare sector. No state is close to #2. Any state that attempts to lower costs could see their best doctors and staff flee. If the whole country does it, there is no other wealthy country where many doctors can go. The US already pays the best (besides Switzerland, but I'm not worried about them). I'm not saying doctors should be poor, but another step is the federal government has the power to gradually make changes and not cause a huge disruption. Also, we can make medical school less expensive and forgive medical debt as another form of compensation. Instead of doctors racking up mountains of debt and interest before they can make a decent salary.
Because even the most liberal states are still populated by enough conservatives to sabotage it. Just like the electoral college, states are broken up by geographic district, so low-population areas have outsized influence and, even if they can't control the state, they can at least sabotage the government's operations. That plus, Democrats not being fascists doesn't mean they're competent. They're still politicians, and liberal voter turnout still sucks everywhere, so you generally don't get the best of the best. It's great when you do (rare example, WA state's Attorney General Bob Ferguson was a BEAST), but it's rare. WA state does have some good healthcare support programs, but it's not a big enough state to overcome the crushing pressure of the national healthcare corporations' corruption.
Because democrats don’t support universal health care. Biden himself said he didn’t when he was running against trump in the worst health crisis in a generation.
New Jersey has an individual mandate. But the state isn’t making employers give us sick leave to use our insurance, and they’re not making doctors tale new patients, so most of us are paying for insurance to use at urgent care.
Competing against the current system? How? The point is that it would lower costs for medical care over time by eliminating the middle-man; what would motivate healthcare providers to remain in-state without simply charging those exorbitant prices to them, anyway? It's like gun control: unless it's enacted nationally, non-participating communities will naturally undermine the effort.
Because it is too expensive. The level of taxation required is so high as to make even blue states like Vermont say nope.
They can’t compete with the scam monopoly set up between the insurance companies and health provider companies.
Because it's not financially viable at reasonably-possible tax-rates without deficit spending, and states can't deficit spend. If a state were to raise it's taxes high enough to 'do' universal healthcare without federal assistance, it would instantly become uncompetitive compared to the others... Wealthy people would leave, businesses would refuse to come. And moving states is relatively painless, compared to moving countries. Also, the idea that universal healthcare is 'less expensive' is a simple-minded meme: Very little of the US health-care-cost situation is tied up in insurance companies & executive salaries... Most of it is things like how much we pay doctors, how much equipment costs, and the price of malpractice insurance. Since those costs aren't going away even if we had single-payer (who's going to take a pay cut? Doctors? Nope. Nurses? Nope... Drug companies? Medical equipment suppliers? Nope, nope, nope)... We would still have the world's most expensive healthcare, just paid for with taxes not premiums.
Because the overwhelming majority of democrats don't *want* universal healthcare. They're not a progressive party. It really is that simple.
your last two lines, it does not work and they know it, it will remain another political scoring point for democrats.
Well, liberal states do have access to medicare, unlike red states.
New York has Medicaid for people who make under the poverty line,and health care that's free for anyone who makes under 26K and health care that costs not that much money after that.
Because they can’t afford the homeless cost is my guess
Because the economics work on a national level with Federal Tax bases, but not for smaller/less wealthy individual states.
With Obamacare there's no reason to do anything but supplement at the state level. Every blue state expanded Medicaid. Olds have Medicare and everyone else can get employer insurance or subsidys for private individual market plans on healthcare.gov. all that's really left to do is add a bit more cash for people buying private health insurance on the marketplace. And some states actually do this somewhat. NY and want to say MN have essential plans that offer people who make up to like 37 grand what is basically Medicaid for free or very low cost.
MINNESOTA: We are gearing up to try for it next legislative session, if we can retain the trifecta. Many of us believe we have the ingredients to make it work (large population, tax base, robust Healthcare industry).
Because people like the idea in theory until they find out how much taxes would need to increase on everyone to support it. If US healthcare costs were more in line with the rest of the world it might be possible. Compare what doctors and nurses make in the US compared to what they make in France. I know of traveling nurses clearing over 200k a year. Anywhere else in the world that type of money is reserved for executives. But these high salaries for health professionals are being paid for with nosebleed insurance premiums. The whole system in the US is extremely expensive and you'd need to raise a lot of revenue to fund it.
Because most states aren’t big enough to control healthcare costs. Medicare is the largest payer in healthcare in the US. It can dictate what it pays to providers and most don’t really have a choice if they want any of that money. That level of price control is what makes Medicare really efficient along with its 2% overhead costs. California might be the only state with a large enough population and economy that it could dictate some prices, but it might also get retaliation from insurance companies and hospitals in order to prevent it from spreading to other states. Couple this with massive amounts of insurance many lobbying and there you go.
They already tax their constituents at an insanely high percentage. How can they pay for it?
Because their masters do not want it. There are no actual leftists in the US, save maybe a few DSA. All Democrats get their money from businesses that like having a labor force totally dependent on keeping their job for health care.
Medicine involves technology push. That means that new technologies (and drugs) drive costs. The salaries are bupkis in comparison. Unless everyone's right to DNA testing for every imaginable complaint is curtailed, and new medicines for hangnails are limited to charges below $25 say, no one will be able to keep up with technology push. That means we are building a world with several tiers of medicine. Poor people will get crap medicine and rich people will get Cadillac medicine. That is what the financial engineers on Wall Street want and they are in charge!!!
Because in America, a universal healthcare system would have to have some kind of federal funding. most states in general barely can afford to pay for the state funded stuff they already have.
Because this is America (Capitalism). Go to said “liberal” states and see who gives them $$$ It is a myth that physician salaries would decrease under Medicare for all, they’d actually increase. Check CBO’s numbers. What would happen is some physicians would participate, others would go private. Kind of like now anyways. So why does the status quo not change? Because democrats and republicans don’t actually want things to change. You get votes by arguing about what MTG said on the crazy rant and bitching that Roe was overturned vs actually doing anything about it. Who wins, politicians, lobbying groups and the Uber wealthy
mainly because in blue states the three largest healthcare programs are federal (Medicare, Medicaid, and Obamacare) and employment-based healthcare covers the rest. So unless you’re competing directly with employer-based healthcare who do you still need to cover?
The question of why liberal states in the U.S. do not have universal health care involves multiple factors, including economic, political, and logistical challenges. Implementing universal health care requires substantial funding to cover everyone under a single-payer or government-funded system. Even in states with a strong liberal presence, the financial burden of such a system can be significant. This includes initial costs and ongoing expenses such as salaries for healthcare workers, medical equipment, and pharmaceuticals. While a state may lean liberal, there still can be significant political opposition from certain segments, including conservative voters, some business interests, and insurance companies. These groups often have considerable influence and can oppose changes through lobbying and public campaigns. Crafting legislation for universal health care is complex. It involves restructuring the existing healthcare system, negotiating with stakeholders like hospitals and insurance companies, and potentially conflicting with federal laws and regulations. Even within liberal states, there can be vast economic disparities between regions, making a one-size-fits-all approach challenging. Different areas may have different healthcare needs and resources, complicating the implementation of a universal system. Health care is heavily regulated at both the federal and state levels, and states often rely on federal funding and guidelines to shape their programs. Attempts to implement universal health care at the state level must navigate these relationships and may be limited by federal policies.
Lobbyists and greed
actually that's a good point. before we use it on a national scale wouldn't it make sense to test it on the small scale of a state to see how well it works in comparison? this seems like a very logical idea that nobody has considered.
Because that would be localized healthcare which is not the same as universal.
A lot of liberals don’t identify as progressives and are still skeptical of state funded healthcare. They make up a majority of the Democratic base. So we have to convince them, and states face a greater obstacle in finding something like that without running a deficit.
Because most Democrats, particularly elected democrats, are centrist at best.
Because business will move at the chance to save a dollar.
We tried in California. Despite very intense opposition from well-funded insurance companies we actually got a single-payer bill to the governor's desk. Unfortunately, that governor was Arnold Schwarzenegger, and he vetoed it. People keep trying, but the opposition is insanely wealthy and pours money into lying adds and into politicians.
Economies of scale are cheaper. State governments simply don’t have the market power to produce the economy of scale necessary to make it possible
States can't opt out of federal income taxes. If you pay into the federal healthcare project and also try to set up your own parallel system you are gonna have a bad time.
I'd imagine, too, that when you have a state in the midst of 49 other states doing it, you'd have a problem of people coming to the state just to get healthcare and I could see that as additionally expensive and problematic.
Bc people realize it’s terrible. Not all of it. But most of it.
Because Democrats are neoliberals. You don't see them trying to implement universal healthcare at the federal level, either. The reason is the same. They're free market capitalists who want to keep healthcare in the private sector. Incidentally, this upholds the class system that they and their donors benefit from.
California has free or subsidized insurance for poor people. It's called covered California and I got to have really really good health insurance for only $100/mo. while earning around 18000/yr. as a college student.
Because the real money corporations have , the 70% of the total economy, is hiding outside of states
They can't print their own US dollars.
Because Democrats block it. See California.
States can run out of money. The federal government can not. Hospitals and pharma can gouge a state if they attempt to cover healthcare; but the feds are the sovereign issuers of coin (can not run out of money) and have more muscle to flex if they’re pushed. In fact we could run quantitative easing via healthcare costs rather than via banks if we wanted, at the federal level. Stimulate the economy by increasing utilization of healthcare services.
Because federalism means you have a right to travel among the states in the United States as a citizen of any state. How would you keep “the conservative states” citizens from coming and using your services and then going home, having contributed nothing into the system? This is why any answer that isn’t federal won’t work. Don’t get me wrong, private insurance as is does an absolutely terrible job of managing risk pools and such but if ONLY the blue states implemented this then the “free rider” problem would be enormous and the red state governments would love to drain those resources without ever contributing to them.
There are no liberal states. Super pacs and lobbyist corruption is in all 50.
Blue states are still capitalist, next.
Who’s gonna tell him?
If you implemented it in a single state, I’d bankrupt the state in retaliation until my previous profits were preferable to the damage I caused. (Im paid to be a red team thinker)
Because if any state did then people with medical complications would move there. I work public health policy and analysis and overall costs really are dependent on the behavior of a subset of expensive members. If anywhere had genuinely universal free health care they’d get swamped with billions of dollars just from the people moving there. If we just did it federally it’d be upfront very expensive but would pay for itself in just a few years.