Would you need a refund?

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!

This is what Australia does, I think. Single payer public option, but you can choose to buy private health care as well (though you still pay taxes for the public option regardless). I'm curious to hear from any Australians about how this system works for them.

It seems to work okay for the most part, and the population of Australia is much smaller than that of California so I don't believe it would be impossible to do by itself. There are always political discussions in the background about changes to cost or services, but it has a high level of public support across the spectrum of politics, which helps.

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.

Yes, this is how things work Down Under.

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.

I use to work pretty well for me. Note I haven't been there in 4 years.

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.

You actually pay more taxes if you do not choose the private option. Though private insurance is generally more expensive. Over the years since it was introduced, there was an exodus of sorts from public to private due to this incentive. It has recently started to turn as insurance companies have been drawing more profit than the value they provide.

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.

Deleted because the sibling comment posted at the same time is more thorough.

I know others replied but I'll try to do a full, in-depth explanation of how it works here because the alternative is that I do producive work after lunch and screw that.

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

I can understand it, but it's basically a classist system. The advocates are saying rich people are better than everyone else, they should be able to bribe their way into better health care because they can afford to. A single payer system that puts everyone, regardless of race, class, age, at the end of the line - and as they do not like how things work, they fix it. What's important is creating the auditing mechanisms for identifying and evaluating problems, prioritizing them, and then getting them fixed.

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.

How do you know it will be substandard?

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...

Most people are provided healthcare through work and are not given an option of what healthcare to buy.