[3] mentions that tax revenues will fall because of the end of temporary tax increases; those increases are likely to be renewed.

Categorizing these as 'severe budget issues' is disingenuous and misleading. California has had a bumper crop in terms of tax revenue over the past decade, and this stupid meme about California being out of money needs to be corrected.

That being said, health care is not an inexpensive line-item, and will have to be funded with taxes.

But as a Californian, I'm sure as shit happy to pay more in taxes for a universal single single-payer. I have many friends who are either contractors or who earn very little and find themselves in that uncomfortable valley of having to pay for expensive insurance -- I'd rather that people (like me) who are better off financially foot a bit more of a communal bill so that no one would need to worry about it.

  California has had a bumper crop in terms of tax revenue 

And this doesn't even count the huge infrastructure deficiencies and deferred maintenance.

[0] http://www.pressdemocrat.com/news/6563825-181/19-billion-err...

tens of thousands of local government entities issue bonds, and some employ dubious accounting techniques “that obscure their true financial position,” according to a 2015 report of the Volcker Alliance https://www.city-journal.org/html/zeroing-government-fraud-1...

Yes, and that's the problem. It's funding is at 73% and dropping -- that 27% is an astronomical deficit.

Numbers here: https://www.calpers.ca.gov/page/newsroom/calpers-news/2017/a...

In that case stupid question: if CalPERS owes much more than it can afford to pay, where is the rest coming from? The LA Times article, in multiple places, talks about how much the shortage will cost the "taxpayers" (see quote below for example), how is this not related to the CA budget which is, well, funded by taxpayers?

> "This year, state employee pensions will cost taxpayers $5.4 billion, according to the Department of Finance. That’s more than the state will spend on environmental protection, fighting wildfires and the emergency response to the drought combined."

That makes it seem like it's related to the budget...

Also, when tax-free pension contributions go up and taxable payments to future retirees go down... then taxes collected also goes down...

As for a change in tax revenue, the same is true if you contribute more to your 401k and/or get back less because your investments didn't do good. Also, if you lay state employees off, your state income tax revenues go down.

It could be funded by increasing contributions gradually until it reaches the correct funding level (either from cuts in other areas or taxes), by cutting the future amounts they distribute from the pensions, by raising the retirement rate of current workers which would give them time to make up the deficit, or a combination of these.

The problem is, these options all kind of stink politically, but they won't bankrupt the state by themselves.

As someone who just climbed out of being a contractor and into a full time position, I concur. Raise my taxes for this. Please do it, and do it soon.

Ok, fine, create a public option. But don't force me to buy it. Let me buy my own healthcare.

Would you be OK with a requirement that you do, in fact, spend the refund on health insurance?

Otherwise I see a problem where struggling people opt out of the care, to get cash to pay for other emergencies, and then the state ends up footing emergency room bills anyway, and premiums are out of whack due to decreased enrollment by healthy people.

Also, what happens if your private care falls short and you show up one day at the State emergency room? Do we refuse you care because you opted out? Emergency rooms need to give care to everyone, that's the point it's an emergency and you don't want to have your care waiting on your paperwork being out of order in an emergency.

If we can reserve part of your refund to cover such situations, I'm ok with it!

The main thing to consider is that the tax base is much different from the U.S. There is an across the board GST which is managed federally, so no local/state options. The income tax overall is higher, though the part that is earmarked specifically for healthcare is only a small percentage of overall income tax. This means that general revenues make up a larger portion of funding than it would appear from a single item on your paystub.

Also, the pricing for public health services is heavily regulated, though there are completely private hospitals and clinics that are separate from that system. Ambulance is also separate from the system, which means either a local tax in some areas or you would need to pay for insurance coverage.

Overall, patient cost is lower, but take-home pay is also lower. Also, I don't believe you can make a sustainable public system without also having a large number of regulated "public" clinics and hospitals. If done correctly, I believe there would be alot of buy in from doctors and other professionals who are just as tired of dealing with the payment headaches as patients are. But you have to get alot of buy in from both them and patients to make it work, and you need an option for people who want to pay for their own "cadillac plans" if you want to keep insurance companies and the very wealthy from getting upset at the effect on choice and lifestyle.

There is a universal public health care system that everyone is part of and funded via Federal Govt taxes. This allows anyone to be treated for free in a public hospital. Given your condition and severity of the problem, you may have to wait for treatment.

This system works quiet well overall.

There is also a parallel private insurance system and privately owned hospitals. Which you may choose to be treated in if you have/can afford the insurance. Top private insurance cover for a family can run to about AUD$5,000 per year.

If you earn over a certain amount of money a year ($90,000+ for singles and $180,000+ for families) you will pay more tax if you do not have private insurance. This is to try and push those that can afford private insurance and treatment into the private system, to free up resources in the public system.

When I left if you earnt over (iirc) 40k per year, you had to purchase private health insurance. Im happy with that.

I did have to goto hospital a few times, I shattered my elbow joint and required 3 surgeries to repair it in total.

The cost was under 5k in total if I remember correctly. I went to public hospital first, but for something like this they recommended private(which I had at the time) - that way there was less waiting, 2 days later I was having my first surgery.

It helps that the standard of care in Australia, for significant or life-threatening health situations at least, is generally as good if not better in the public system. For everything else, insurance or otherwise, the only way to get quality healthcare is money and contacts.

As a system of encouraging higher spends on healthcare, private insurance works.. The only issue is none of the profits of that system goes towards better healthcare. It is just more damn rent.

Everyone earning a taxable income pays a "medicare levy" of 2% of your total taxable income which funds the public system [1]. You pay that regardless of whether you use it or not - it's a fixed part of your income taxes. There are waivers for low income earners as detailed in [1] so that teens working in cafes to get through uni aren't smacked with extra taxes but by and large if you're a fulltime employee you'll be probably paying it.

In addition to that, you pay another 1-1.5% of your total income (1% for $90-105k, 1.25% for $105-140k and 1.5% for 140k+) as the "medicare levy surcharge" [2], however you get a partial or full refund of this if you have private health insurance. This encourages high income earners to take out private health insurance, ostensibly to shift the burden off the public health system because if they have private insurance they're more inclined to use it.

Lastly, if you do not take out private health insurance once you turn 30, your premiums on private health insurance increase by 2% per year for every year that you don't hold it over 30 (with some exceptions) [3]. After 10 years of paying this increased loading on fees, it disappears (ie: if you take out private health insurance for the first time at 40 you'll be paying 120% premiums until 50 then it'll drop back to 100%). This is supposed to incentivise people to take it out earlier in life and hold on to it, rather than take it out towards the end of life when they get sick all the time. By doing so, it (in theory, i'm dubious) keeps down premiums for everyone overall because private insurance companies don't have to price in people only buying it when they're sick.

As for how this works, I think it works pretty good on balance. Everyone gets a green medicare card at age 18 (under 18 they're on their parents one, unless broken families etc. necessitate an individual one earlier) and it entitles you to basically walk in to a public hospital and get care if you need it, though the public system usually requires waits based on your current state (ie: even if you're in emergency with a broken wrist, they'll put you aside with some painkillers if there's someone with an exploding appendix presenting at the same time). It also covers other procedures that are non-life-threatening, though there's significant (months+) wait times - you go see a specialist who registers you into the public system for a procedure, then you wait until you get a letter in the mail setting a date for your procedure. Even for semi-urgent procedures there might be waits of months depending on how muc hdemand there is, though to their credit the public system does try to keep tabs on whether your health degrades during that time and will prioritise you accordingly relative to others waiting for the same procedure.

I had a completely non-life-threatning, almost cosmetic surgical procedure in the public system and I was waiting for about a year or so but given it had no effect on my day to day life I was happy to wait and it meant it was completely free. I saw my GP and he referred me to a specialist (who I think saw me under the public system, so I didn't pay for that). I saw the specialist and he scheduled me for the procedure. When I got my date for it, I went in mid-morning, went under a local, woke up a few hours later and walked home that afternoon with absolutely no out-of-pocket cost to me whatsoever.

The quality of healthcare is reasonable too - many of the specialists who work in the public system also work in the private system for a couple of days a week to boost their income, so it's not uncommon for a specialist you consult with to ask which way you want to go before they direct you to whichever relevant hospital they practice at. The public system also tries to facilitate cross-hospital discussions about particuarly interesting cases, for example doctors from multiple public hospitals in a city will come together to share notes and ask for opinions to help deliver better outcomes. Private, by nature, doesn't necessarily get that exposure.

The private health insurance system here is national - just about anyone in any state can get any policy, more or less. There's easy comparison websites that let you plug in your details and get a quote [4] and they offer all kinds of ranges of cover from 'I want to avoid the surchage for tax purposes, please insure me as minimally as possible' (at about $70/mo in my experience) to 'I want to be able to walk in to a private hospital for absolutely any reason and not pay a cent, please charge me all of the money in fees' ($x00s/mo easily from what I've seen). Cover is sliced into 'basic hospital' cover and 'extras' cover which lets you tailor the two with greater flexibility. Changing between providers is nearly frictionless and that helps keep fees down since they're all competing. The government does place some regulation on the levels of fees and how much they may increase each year, to try to manage costs of private insurance. There's also strict rules governing pre-existing conditions, etc. that you hear about from US insurance horror stories.

The public system is not without its faults for sure, and many people will rubbish the public system as a bad one due to its wait times, its relatively reduced level of personal focus by staff, increased patient:staff ratios etc. but it does remarkably well for the funding it has and is vastly preferable to it not existing. Those who want a private experience can easily get it but those who can't afford it at least won't rock up to a hospital with a broken foot only to be turned away. In that sense, it serves its purpose well as there's the incentive for people to pay to move off the public system (thus managing its burden) whilst ensuring that if you absolutely do need help, you'll get it.

[1]: https://www.ato.gov.au/Individuals/Medicare-levy/

[2]: https://www.ato.gov.au/Individuals/Tax-Return/2016/Tax-retur...

[3]: http://www.privatehealth.gov.au/healthinsurance/incentivessu...

[4]: http://www.iselect.com.au/ as an example if you want to play around

But the reality is, the for-profit system already forces people into a substandard single payer system in a huge portion of the U.S. where there's only one insurer, not least because health insurance is an anti-competitive business but aren't regulated per competition law.

From my travels to New Zealand, I'd argue their single-payer health care experience is overall better than here. You can buy private insurance there which supplements the public system and lets you visit private hospitals outside of the public systems, but you don't need it for emergencies or standard GP checkups. Most people don't bother since the public system is good.

And from a tax perspective, according to the BBC, the US effectively taxes an average income single person at 22.7% while NZ taxes at 16.4% [1]. For the top bracket, in US it is 39.6% while in NZ it is 33% [2][3]. I'd argue they are getting a much better deal than us. And don't forget the US numbers are before health insurance is paid.

So, it is definitely possible to get a good system. I think one of our major problems as a country is that we lack transparency which undermines trust and makes it easier to corrupt the system. You can't run a good health care system without transparency and accountability, regardless of whether it is a public or private system.

Cheers!

[1] http://www.bbc.com/news/magazine-26327114 [2] https://www.irs.gov/pub/irs-pdf/i1040gi.pdf [3] http://www.ird.govt.nz/how-to/taxrates-codes/rates/itaxsalar...

It's 'separate' from the state budget, but doesn't California still ultimately pay for pensions? How is this fine when there's a huge difference between the projected costs and the actual costs? Doesn't 70% of CA tax revenue go towards paying pension obligations?

Current CA pension debt is $965 Billion.

http://news.stanford.edu/2015/10/15/cali-pension-tracker-101...

http://www.pensiontracker.org/index.php

  Doesn't 70% of CA tax revenue go towards paying pension obligations

Maybe you got the 70% figure from where CalPERS gets its funding? Currently yearly contribution is ~70% from the state, but there was a bill passed that is shifting some of the requirement on to those who will benefit from it.

Yes there was a new bill and there was a shift, but most of the burden is still on the state of California which makes sense since CALPERS is an agency of the state of California. Isn't CA still ultimately responsible for CA pensions?

I just felt that CALPERS was in trouble years ago when they were selling their members an advancement in years for the pension if they paid a fee upfront (which could be deducted from their paychecks) in order to meet current pension obligations.

Current CA pension debt is $965 Billion. It'll become $1 Trillion soon.

http://www.pensiontracker.org/index.php

There is crux of the issue: not everyone shares the same opinion and belief, so should the government force those people to spend their earned income on healthcare for others? Personally I think it won't end up how you anticipate but that's just me. Right now the working people of America are already subsidizing healthcare for the masses and all I ever hear is people complaining about it.

Yes. Ideally, that's what governments should do: require citizens to act in our collective and long-term best interests, not only their own.

In the case of healthcare: a healthy population is a productive, happy, and peaceful population. All of those things are good for the economy, not to mention any one particular person's soul -- you can make a completely utilitarian argument for it and largely sidestep thorny issues of morality.

Could you please inform our population here about that?

Republicans keep promising that people will flee the Blue states due to various policies; somehow it never seems to happen.

Could you let us know what we're doing wrong? We'd really like to send some of these folks to Red states to help balance out the voting.

Thanks bunches.

"Every year from 2000 through 2015, more people left California than moved in from other states. This migration was not spread evenly across all income groups, a Sacramento Bee review of U.S. Census Bureau data found. The people leaving tend to be relatively poor, and many lack college degrees. Move higher up the income spectrum, and slightly more people are coming than going.

About 2.5 million people living close to the official poverty line left California for other states from 2005 through 2015, while 1.7 million people at that income level moved in from other states – for a net loss of 800,000. During the same period, the state experienced a net gain of about 20,000 residents earning at least five times the poverty rate – or $100,000 for a family of three."

Life in California is becoming a luxury good, largely due to its own policies, and that is not a state in the right direction.

I think this would actually be another great lock-in feature, on top of rent control and Prop 13 making it so nobody would ever want to sell their house.

That's starting to sound a lot like Marxism where the value of the individual is less so than that of the collective (Government / State).

I'm sorry but no thanks. Who determines what our best interest is? The only person on this planet that can determine my best interest is me. If I'm incapable of doing so for myself then that is too bad.

If you want to live your life alone in a forest somewhere, you can pay no tax and make all your own decisions.

Healthcare is a SERVICE that someone PROVIDES to you for MONEY. It has a tangible COST. It is not a RIGHT which is something that WE as a COLLECTIVE have determined WE individually possess (liberty, right to bare arms, freedom of press, right to assemble, etc)

That is the bedrock issue behind all the arguments on this topic and why (despite idealistically admirable), universal healthcare will likely never happen...

To make it clear, personally I am not opposed to doing everything we can as a society to bring the cost of healthcare down and make it available and affordable to as many people as possible. But to guarantee blanket coverage for ~325M people is not realistic.

Adding up the population[1] (in millions, rounded down) of all countries in Europe with universal healthcare[2], except the 144 million from Russia, which is mostly asia anyway, I get to 484 million people covered by universal healthcare.

This includes countries like Germany (81M), France (66M), the UK (65M), Italy (60M) and Spain (46M), which should alleviate the fear of 'small European countries can do that, but not a state as big as California'.

[1] https://en.wikipedia.org/wiki/List_of_European_countries_by_... [2] https://en.wikipedia.org/wiki/List_of_countries_with_univers...

Heck, it could even help our economy, because you probably don't buy your own health insurance anyways, but get it from work. Take away that burden from the companies, and it could actually make them more competitive.

I even have one personal anecdote - on a recent trip to Disneyland with some friends, a friend of mine got sick and needed to see a doctor. He had purchased travel insurance, so called the insurance company to figure out where to go. It turned out that the only walk-in clinics covered were halfway across LA. There were other clinics within blocks of our hotel, but they weren't covered. So, he basically wasted an entire day. Now, compared to serious healthcare issues, obviously this isn't a big deal. But still, the experience was just alien to us. Here, if you need to see a doctor, you either book an appointment with your family doctor, or if you need to see someone sooner or it's more convenient or whatever, you just go to a clinic. Any clinic doctor will see you, and will bill MSP (the provincial health plan).

Again, our system isn't perfect. Compared to someone with good coverage in the US, our wait lists for major procedures are generally longer. It's occasionally debated whether private clinics should be allowed to perform these procedures, allowing people who can afford it to jump the queue. The theory is that this leaves more public resources for everyone else, so it's win-win. However, generally politicians steer clear of anything that sounds like private health care, because in general people fear any erosion of the public system. (For example by having good doctors go to private clinics.)

Anyway, that was a bit of a tangent. The point is, there are intangible benefits to single payer healthcare that I don't see often discussed in the US.

However, when I ask if they'd be ok waiting over a year for joint replacement surgery, they get a weird look on their face. Or, if they have cancer, they aren't going to get to go to the best cancer center in Canada, you go to your local hospital. And if you want the latest and greatest cancer treatment? Well, you'll need to pay for that yourself since the gov't hasn't yet approved it for reimbursement.

There are benefits to both systems, but it's disingenuous to say that a single payer system solves all problems.

> waiting over a year for joint replacement surgery

1) Remember that many Americans have no access to healthcare outside of emergency rooms; they wait forever. I know plenty, including connected people, who wait months for simple appointments. A year before surgery wouldn't surprise me at all.

> if they have cancer, they aren't going to get to go to the best cancer center in Canada, you go to your local hospital.

2) Again, many Americans wait forever. Few others go to the best treatment centers in the nation - how much capacity do those places have, and who is filling up the local facilities?

> if you want the latest and greatest cancer treatment? Well, you'll need to pay for that yourself since the gov't hasn't yet approved it for reimbursement.

3) Again, some Americans get no funding. Most others are limited to what their insurance companies cover and often have the same problems.

There is a very big chunk of the US that has very expensive (that they can afford) and very good healthcare.

As a result, there are very few private options for healthcare in Canada.

A system where almost everyone is OK and the rich can pay for the best care available is far, far preferable.

The US private health care system doesn't mean everyone who gets cancer goes to MD Anderson. And, you'd still be very hard pressed to have many private insurance plans cover truly experimental treatments. If I had to choose who gets advanced treatments between those who can pay the most vs those who need it the most I'd go with the latter.

It's funny, many of my Canadian friends talk about the "you can't get the best treatment in the world" problem with their system which, to me, shows how they really don't understand the dire nature of US health care. Wait a year for a surgery? Millions of Americans can only go to emergency rooms.

The US health care system even for the middle class is a disaster. Deductibles are often nearly 8k or higher alone! And nearly ALL plans have "networks" so you can't go to whatever doctor you want anyway. (One of my canadian friends doesnt even know what a deductible is!)

You realize there are nearly as many Americans without any insurance as there are people in Canada (27M vs 34M)? And this was AFTER the ACA expansion.

I get trying to post an alternative view, but it's so out of wack. Have you experienced the US health care system for an extended period of time personally? It sounds like you haven't.

My point is that the US system has problems and the Canadian system has problems. Hell, the Canadian Supreme Court ruled that healthcare wait times combined with a ban on private care violated the Canadian Charter of Rights and Freedoms[1].

There are numerous examples of Canadians either suffering in pain or heading to the US for surgery due to wait times.[2]

Bennett was referred for surgery on her right hip in November of 2013 and said she’s been told she won’t get in until early in 2016. She said her joint has deteriorated so much she is unable to work or even function without strong narcotic painkillers.

[1]https://en.wikipedia.org/wiki/Chaoulli_v_Quebec_(AG) [2]http://www.cbc.ca/news/canada/british-columbia/patients-live...

Sometimes Americans go to Canada for medical treatment, and sometimes Canadians come to America for treatment. It's not a simple better/worse situation.

Just having decent health care is a struggle in america. if you don't have a job and you are not independently wealthy you are basically screwed pre-ACA.

Not having a single payer healthcare in america also changes the risk calculus of starting up your own business.

The thing to recognize is that the every-person-for-themselves approach leads to outcomes that drive costs up extraordinarily. Avoiding the US model is why every other OECD country offers universal coverage and boasts longer lifespans, even though health care costs them one half to two thirds less a portion of their GDP.

For all its bleeding-heart, hippy commie values, the major advantage of single-payer is massively reducing the costs of health care, and making life very hard for anyone not directly creating value. This is bad news for rent-seeking holders of pharma patents and CEOs of private insurance companies making $20 million per year, good news for just about everyone else.

It comes down to this: will you accept that some forms of socialism work in return for getting a better deal on health care and the indirect benefits of living in a society where access is a given? Or are you so ideologically committed to free-market fundamentalism that you would rather waste more of your own money and live in a more unstable society because hey, that's how John Wayne did it.

It's cheaper because less is offered. Of course one can argue the extra you get under the US system doesn't really add value.

Keep in mind that single payer systems are struggling with costs as well. It's just easier for them to say "no one gets this new treatment".

And yes, you can very easily argue that many other costs don't add value. That's why pointing to the superior overall life-expectancy in other countries is such an important part of the argument. On balance, every other system in the developed world does more, for more, with less. Our system offers bottom-of-the-pile rankings by every major measure.

Finally, "struggling with costs" is a non-starter as far as arguments against single-payer go since what things cost and how you come up with the money are clearly two different things. Saying "country X is having a hard time funding their health care system at 10% of GDP" in no way undermines the case for dumping a system here in the US that costs us closer to 18% of ours.

Seriously, we could make massive improvements to ours simply by picking the name of any other OECD country from a hat, and just implementing their system. Literally anything is better than what we've got here, and it's not even close.

There are plenty of drugs you can get in the US that single payers systems simply won't cover. The Cancer Fund in the UK is a great example. NHS said "nope too expensive" to several drugs so unless the Cancer Fund pays for it, you're SOL. That's how single payer systems save money.

That's why pointing to the superior overall life-expectancy in other countries is part of the argument.

Life expectancy is a very blunt tool when you're looking at level of healthcare. There is too much intra-country variability.

The point of controlling costs is to provide incentives for developing drugs that not only work, but that do so at non-ruinous prices.

And also, the cost of those HCV therapies is actually cheaper in the US than in the EU.[1]

[1]https://www.forbes.com/sites/johnlamattina/2015/12/04/for-he...

We do pay for the roads in Los Angeles and EVERYONE complains about the traffic. People bitch about everything

> all I ever hear is people complaining about it

Government funded healthcare is widely supported in the U.S., including Medicare, Medicaid, and the Affordable Care Act.

Great, you can opt in to that, but don't force everyone else who doesn't agree with you to subsidize everyone else's poor decisions

No one is interested in allowing you to live in a country without paying for it. You live under the permission of others.

Them's the rules - take it or leave it.

The US government spends more per capita on health than the UK government does.

Oh, wait, that's what society is--we all pay for communal stuff because we're all ultimately in this together.

No, that's what socialism and communism are.

https://news.ycombinator.com/newsguidelines.html

A single tax that you can plan for without worry and just get on with running your company? Sounds good to me.

Please don't vent snark like this on HN, even when someone else is wrong and/or started it. Your comment would be just fine without that.

Under single-payer, CA employers will no longer need to provide insurance for their employees. That money could in some way pay for this. It also makes the idea of a 'gig economy' much more palatable, since people working in short-term / part-time situations will no longer have to go without employer-provided insurance. It could be a source of further economic growth since that makes CA a much more friendly place to start a business.

More centralized healthcare systems also have two arguments for driving down cost - one being that such a system is more effective at promoting timely / preventative care (which is a lot cheaper than emergency care). The second is that such a system can negotiate prices with providers more effectively, and invest in long-term projects to reduce the cost of care, driving down the cost of healthcare overall.

Thus far I have been able to resist the tempation to do so.

That's for charitable contributions...

If your proposed solution doesn't start with a plan to bring healthcare costs into line with the OECD average, then even if your plan works it's like trying to bail out a leaky boat by scooping water up and pouring it back into the boat.

This one...doesn't even try. Yes, if health care cost the same in the US as it did in Germany this plan would work great...but it doesn't. You can paint a Yugo red, but it doesn't magically turn into a Porsche.

(And before anyone asks...no, the best estimates of potential savings from switching to single payer is orders of magnitude too low. The NHS works because medical care is cheap to provide in the UK; medical care isn't cheap to provide in the UK because of the NHS.)

That is to say, we've reached a scale where we absolutely can start thinking and acting like a nation state. That doesn't mean that smaller, poorer, and weaker states can simply copy what we do directly, one-by-one. But it does mean they can band together to see that a demonstrably good model gets implemented at the Federal level.

(This is true, incidentally, because in large part NZ's low costs come from just buying less stuff. Fewer fancy drugs, fewer fancy machines, smaller and older hospitals, and lower salaries for doctors and nurses. Works great, but this is politically infeasible in the US, to say the least, which is probably why California isn't even dreaming about trying it.)

Yes, California has 38 million people or whatever, but other large groups of in the US can't get good deals (be that insurers like Aetna or Kaiser, or government programs like Medicare). They're not larger than Medicare, so that's out. Are they going to be greedier that Aetna? Really? Or is the famously dysfunctional and lobbyist dominated government in Sacremento going to make some hard choices and piss off the voters?

> But it does mean they can band together to see that a demonstrably good model gets implemented at the Federal level.

I'm a very strong proponent of federalism and the states as laboratories of democracy and all that. But... What California is proposing to do is not really new or untested. It's an expansion of a system that already exists in the US, and closely replicates systems from other countries. Yes, it works great if costs are low, and will bankrupt the state if costs are high. Costs are currently high. How do you square that circle?

Hospitals and pharmaceutical companies then negotiate directly with the state. And as far as what they can be expected to accept without going out of business themselves goes, we can get a pretty good idea from the expenditures of every other OECD country.

The trick is whether the transition to a single payer system is feasible. Both in terms of taxes, and existing organizations and incentives.

Except Canada can (for the most part) control who can enter, stay, and participate in the system, while California is at the mercy of its open borders (newcomers from other states or countries).

This is the same flaw (see Strong Towns) that leads cities to tear down useful buildings and replace it with parking lots and highways, because the federal government gave them money to build them, but not to maintain them… so they go broke.

Huh, I just realized I'm wrong because California voters always approve state bond measures. We're safe after all.

https://en.wikipedia.org/wiki/List_of_U.S._states_by_GDP_per...

One point about our size. When CA does something at the state level a lot of other states follow along. Minnesota can't dictate to manufacturers but CA can.

Overall population/economy size matters, not just per-capita.

By comparison, Mississippi cannot afford this. They're basically supported by states like California; their economy is trivial and they're propped up by defense spending.

Why do you think Apple gets better prices than, e.g. Logitech for component parts? Because they order massively more, up-front, and with strict timetables for delivery.

To be very clear, I think CA can afford this and I think we should do it.

Ben and Jerry's can only foot so much of the tax bill.

The above is of course talking about newly developed drugs. There is however a rather disturbing recent predatory practice some drug manufacturers have started to engage in of either purchasing an existing drug and jacking up the price if they're the sole manufacturer, or else making a trivial change to an existing drug and then re-releasing it at massively inflated price. In either case the effect is the same, they're selling a drug that has no appreciable research costs associated with it, just the manufacturing price, but they're continuing to charge as if they were having to offset the research costs and they get away with it because that's what people are used to.

None of the players above (including apple) engage in cost based pricing. They all charge the price that maximizes their profits, not the price that sells the most units while breaking even.

That said, the future of the Affordable Care Act is currently unclear.

[1] https://en.wikipedia.org/wiki/Patient_Protection_and_Afforda...

"Ultimately, Thornberg believes California would be better served with a Texas-style tax revenue system where there's less reliance on personal income taxes and capital gains tied to the stock market, and more of a focus on property taxes and sales taxes."

So long as high priced real-estate are exchanging hands, CA will reap the benefit.

Prop 13 incentivizes homeowners to stay put until they die. In other words, it puts tremendous downward pressure on the housing supply which results in a self-reinforcing feedback loop whereby the more real estate prices grow the greater the tax incentive to stay put.

Changing this state of affairs is near impossible. Nobody is going to trade increased mobility and a more efficient housing market for a precipitous drop in the paper value of their primary asset, even though on the whole it'd probably be better for everybody.

Why precipitous? Because locking in, under Prop 13, your first year property valuation is a huge part of the calculus for determining affordability and your bidding price. If a new home owner doesn't get the benefit of Prop 13, he's going to pay far less for a house. Which means you can't even ease California out of the cycle by grandfathering existing homeowners in the hopes of avoiding their ire.

Repealing Prop 13 just isn't politically viable. It's a fascinating state of affairs.

California does not have that problem.

ding. Got it in one.

Normal residential properties transact roughly every 10-15 years with 40-50 years being on the way outside. So, most residential properties aren't too far behind their real value in taxes.

Commercial properties never transact; they just add more subleases. We had one property we rented which had 23 layers of sublease to avoid Prop 13.

Anyway, there's no reason it's a financial funding problem. No matter what it's some kind of tax. Either it's a government tax for a government operated health care system (single payer); or it's a tax on the business vis a vis employer based insurance where they are the true customer not those who are insured; or it's a tax on the employee getting a plan on the market place if the employer doesn't provide one.

The number one problem is that it's simply too profitable for doctors, hospitals, clinics, and insurance companies right now, to have system that incentivizes pay per procedure per per visit, rather than paying for health. It is not health care, it's sick care. Very little of our system incentivizes health. A miniscule number of insurers pay if you actually show up at a gym, not merely pay for the gym; or pay you to lose weight by actually getting weighed at an approved clinic, and so on.

It's presently politically untenable that we have for-profit education to become a doctor, and salaried doctors.

And there probably isn't a way to make this work on a scale like Vermont. It's probably possible to do it on the scale of California, but deeply depends on the politics.

Democrats basically took a dump on ACA. They tried to get Republicans on board, which is why they went with the Heritage Foundation plan. But then Republicans didn't go for it anyway. So what they should have done, hindsight being 20/20, is offer Americans a way to buy into Medicare rather than set up all these stupid state exchanges to expand a busted for-profit system. Oh well!

[1] This shows how crazy the current spend is already. https://i.redd.it/6srj4xgpmriy.png

False. California has a budget surplus of nearly $3 billion and will be able to weather a mild recession without major budget cuts or tax increases for the next 4 years.

http://www.latimes.com/politics/la-pol-sac-jerry-brown-budge...

Many places pull it off around the world, though at a national level. Probably few are as wealthy as California.