If California implements a single payer system, it would make people in other states more likely to choose not to get healthcare; if they get sick, they can just move to California.

This is the reason the ACA has the 'individual mandate' to go along with preventing the denial of care because of pre-existing conditions - without some coercive force, there is no reason to buy health care until you get sick.

This is why a national single payer system is the solution.

Surely you could require an newly established resident who wants treatment to pay a portion since they hadn't been funding it directly via taxes, and then add a further penalty if they move back out of state within a certain period of time (to discourage moving in-state just for treatment).

Countries like Germany don't have this problem because they have the power to control their borders. Accessing Germany's healthcare system requires being a German resident. That, in general, requires applying for immigration, which the government may or may not grant. EU citizens can, of course, become German residents without applying for immigration, but every EU state has universal healthcare so there is no incentive to free-ride.

And there's a push within Germany and other countries to limit access to welfare benefits for new residents, even ones from other EU countries: https://www.theguardian.com/world/2016/oct/12/german-governm.... U.S. states don't have the power to do that.

But you are of course right, it's not possible to simply move to Germany just to receive treatment under health insurance. To become member of a health fund you need to fulfil certain conditions, e.g. by starting employment. This applies even to German citizens moving from abroad.

The reasoning goes, it seems, that only bona fide citizens of (say) California will consume welfare in California (you don't move to California to consume California welfare benefits in Ohio). But college education benefits are "portable"; you could conceivably move to California solely for the purpose of accumulating the benefits of a UC education, then take it back with you to Ohio.

Further, the way in-state tuition benefits are structured, the residency requirement is (supposedly) carefully tailored to address just that scenario, by imposing relatively short durational requirements on residency, rather than evidence of permanent residency.

It's tricky to piece out how health care would fit into this rubric. Depending on the condition, you might move to California to benefit from their health care and return to Ohio when you're cured, or you might need to stay in California indefinitely to treat a manageable illness.

However, it is really hard to do it in a fair and humane way; to deny care to people trying to freeload but not deny care to people who aren't.

The whole point of universal, single payer, healthcare is to avoid having to make this determination.

This isn't an issue for a country because the number of new residents (immigrants) is not a large percentage of the total number of citizens. If it was a state, though, that ratio might not work out; there is a VERY large pool of possible 'freeloaders' who are legally allowed to move to the state whenever they want.

I'm confused by your question. Countries with single-payer have the same policy everywhere in the country, so there is no freeloading involved.

Unless you're talking about people coming from other countries, in which case it's handled by their immigration policy.

In Canada, generally you have to be a legal resident (i.e. hold a valid immigration status, not just limited to permanent resident or citizen) of the relevant province, and actually living there for a majority of the time, before being eligible for coverage under the province's health plan.

See e.g. http://www.health.gov.on.ca/en/public/programs/ohip/ohipfaq_...

California would probably have to add a waiting period since not all US residents would otherwise have coverage, as in Canada.

I don't think the US has the same demographics as the other countries where this currently appears to succeed. There are way more people who can't pay in the US, we're far too big for this.

The old "America is just different to everywhere else" argument... we see this from the gun nuts too.

Risk selection is a very driver of prices in health insurance. If you can spread the risk between healthy and sick people, the price goes down. If you can't, the price goes up.

Secondly, having a population that has no health insurance means less prevention, i.e. worse health problems down the road, again driving the costs up

See, this is what I don't get. I'm fairly inexperienced with this stuff, but it's starting to become relevant in my life. Despite my new employer offering insurance, I'm staying on my parents' until I'm 26 (this was part of their policy even before Obamacare).

However, this is the question I've been asking ... why do I even need health insurance? Why can't the money I pay in the form of premiums just be used to pay for my health care? The answer: well, it can be really expensive, so this way the cost is shared. But why is it expensive? Why don't I ask how much something is versus whether my insurance will cover it?

Again, like I said, I don't have a lot of experience, so go easy on me. But I think my questions are valid.

This is a great deal for you. $55 is no big deal and now if your house burns down you don't suffer a tremendous financial loss.

Similarly there is a really low chance you'll get cancer next year. But if you do it could cost a ton (millions of dollars possibly) to treat. So insurance is a good deal for this too.

Now, in the US 2 other things get lopped on to health insurance that make things a bit more complicated:

1) For a lot of people health insurance covers cheap and predictable expenses like an annual checkup. There are a lot of people that think using insurance for this is a bad idea. But some people think it's a good idea. It's complicated.

2) Health insurance (especially after Obamacare) can be a form of social insurance where healthy and/or rich people pay more than they otherwise would so that unhealthy and/or poor people pay less. This reduces economic inequality. There is a lot of political disagreement about whether this is a good idea.

Did this help? I've glossed over a ton of details but maybe it's enough to get started.

Also, skipping your annual health check ups is bad for your insurance company in the long run, so this, at least, they have a huge incentive to make sure you go.

Most people are interested in health care and not health insurance, meaning, we know we are going to use the doctor for something...it isn't a big surprise when your wife gets pregnant (well...I mean...). It isn't a big surprise when you start breaking down toward the end of your life, which is why ~40% of our health care is already socialized via Medicare.

I'm mostly with you in that I don't necessarily think this is a great idea, but that's the general thinking.

1. Though there is less evidence than you might think that this actually works.

Why would you imagine that?

Regardless... You must also then ask the question, whether a "truly free market health care system" would be ethical.

Why do you imagine it wouldn't!? The portions of health care universally not covered by insurance are not subject to the same cost disease of the industry as a whole. Lo and behold, the real cost of eg. breast augmentation is declining (total cost of about 4K)! The cost of lasik has decreased ~50% over the last 15 years, current results are better, and the surgery has the highest rating of patient satisfaction in the entire industry! A similar result anywhere else in medicine in the US is completely unimaginable.

> Regardless... You must also then ask the question, whether a "truly free market health care system" would be ethical.

Nonsense. The important question is: 'would a "truly free market health care system" be more ethical than the current system'.

> Nonsense. The important question is: 'would a "truly free market health care system" be more ethical than the current system'.

If you want to be overly semantic, which you clearly do, that's actually not "the important question" since it actually tells you less than my original question. You care about "a truly free market health care system's" relative ethicality not just in relation to the current system, but also in relation to (all) other potential alternative health care system (like a single payer system)...

Dental work is only semi-elective, and prices are driven down thanks to transparent pricing.

Likewise, one can argue that vision services are also non-elective (e.g. people need to see), and prices go through a very large range.

Many medical conditions are not "emergencies". And even so, I often get referrals from my doctor to external imaging services. If those prices were transparent, I imagine a downwards pressure on prices would happen quite quickly.

To give an example, ultrasounds for pregnancies cost ~$250, ultrasounds for almost anything else are 50% to 100% higher in price. In a similar vein, x-rays at the dentist are next to nothing (despite involving a cool robot that rotates around my head, and a digital x-ray sensor that lets me look at images right away!), x-rays for anything else can end up in the hundreds.

Hospitals would also benefit from transparent pricing, if there was a legal mandate that all suppliers be open and honest, prices would drop for everyone. When a hospital sees that other hospitals in the area can offer the same service at a lower cost, meeting the same quality standards, then they can start pushing their vendors to lower prices.

In addition to not being covered by insurance those procedures are all elective. For elective procedures a free market is more likely to produce better results.

There is no way to make money insuring or treating poor, sick patients. The free market just can't do it.

The inherent problem here is that the math behind traditional free market economics breaks down when it comes to life saving goods and services. There is no equilibrium to be had, because of a combination of issues.

First the answer to how much will you pay to access this live saving drug is "anything" for 99% of the population. Second, life saving services are time sensitive--customers often can't choose a different supplier except the closest one. Third patent law ensures that there often isn't an alternative supplier.

A free market would look something like this:

1) everybody buys their own insurance in a genuinely free marketplace (this is ENTIRELY not the case now and would probably require significant gov intervention to defeat cartel-seeking behavior from insurance co's. There are good reasons insurance is so highly regulated, only the first of which is that insurance companies are highly incentivized to not pay out since they already have your money, and you can't go elsewhere with your claim.)

2) if you can't pay, you die in the gutter.

It wasn't before, so it probably wouldn't serve as one in the future. The issue is that people aren't very good at estimating risk.

I'm young, healthy, and no one in my family has been in a serious car accident/gotten cancer/had a heart attack in the last 15 years. Obviously that happening is a low risk compared to the financial penalty of maintaining insurance today, so why should I worry? Besides, I'm sure I can get some kind of plan from an insurance company if something bad does happen[1]

[1] I'll be sure to look into the feasibility of this statement as soon as I finish all the other important things on my todo list...

I'm really not a socialist, I promise. I just don't see how you'd do it any other better, and it's pretty clear to me that the results are definitively in for our free market experiment.

It's funny how we all pretty much agree the govt should be in charge of stuff like roads, schools, military, police, fire dept, courts, quite a long list of stuff, but adding anything to that is marketed as creeping socialism.

No. It is simply false. Even a 100% free market does not exclude charity.

Lotta people talk about charity as a replacement for government services, but folks give around 3% of their income to charity (tax deductible) in the US. That ain't gonna get it done. Not even close.

People would have you believe they would give more if they didn't pay as much in taxes, but there is not one shred of evidence that is the case based on variations in local tax rates. And that's a hell of a gap to bridge based on a such a dubious promise.

Occam's razor, and the available evidence, suggests that people would just pocket the difference and the poor can go to hell. They're happy to argue the point until they're blue in the face, but if the past year has taught us nothing at all, it's that people are more than capable of crafting any number of passionate arguments around their self-interest, truth be damned.

In all seriousness, state run healthcare is a great idea, but the government is just such a big stakeholder in having a healthy population that I do not see a good reason for it [at some level] to stay out of that line of business. Single payer works, so much better than the current setup...why not start there and try iterate?

right, as long as you ignore 200 years of legal precedent in which it has...

ORRRRR....you do what you've done 27 times before, and you amend the 200 yr old document :) We all make mistakes, sometimes the best option is to own up to them and do something different.

First off everyone dies. Who's not receiving healthcare right now that would be ultimately saved by the government?

Secondly let's cut the hyperbole and have a rational conversation about this.

People not receiving basic preventative care with problems that are only going to snowball until emergency services can try to treat a much more complex situation in the future?

> Secondly let's cut the hyperbole and have a rational conversation about this.

You could have maybe had a point by quoting "but the market will win", but "Americans will die needless deaths from not receiving basic healthcare" is literally what's at stake. What exactly do you think the downsides of people not being able to afford healthcare are?

when they're on long wait lists for procedures because of a glut on resources

when they no longer have access to the high quality care they once had

when there's a greater shortage of quality nurses and doctors because of diminished pay

when innovation is stifled because R&D is funded by the government

Yes it will be complicated, and yes, even if healthcare is guaranteed to all, profit motive is still an important driver for efficiency and innovation.

All of that, but it's still irrelevant to your dismissal of actual deaths due to our healthcare system as "appeal to emotion nonsense".

  because of a glut on resources

It is not irrational to point out the cost of ongoing debate.

No, it's the typical appeal to emotion nonsense that got the ACA passed to begin with. Now that's going to fail before it's even completely applied.

The federal government already pays for 64.3% of healthcare costs http://www.pnhp.org/news/2016/january/government-funds-nearl.... In a centralized managed system this would likely cover the cost of all healthcare. It's roughly what other industrialized nations pay, per person, for single-payer.

Let's say I'm in the business of selling normal goods (say, backpacks). Now, instead of just people going to my website or looking at crowdsourced backpack reviews, there's some cartel that has figured out how to dominate search engines and other sources so that almost all the customers see their middle-man stuff and buy through them instead of directly (even more extreme, maybe they spend massively on lobbying to achieve real rent-seeking via outlawing direct purchases by consumers, although that's not necessary for my argument).

These middle-men charge much higher prices than we'd see if everyone bought directly. But dominating the search-engines while the algorithms constantly change is ENORMOUS work, so these cartel companies pay almost all their revenue to a huge number of employees who work constantly to update their systems and maintain their middle-man dominance. You could say they "barely make a profit!"

So, in that scenario above, it's painfully obvious that the system is horribly wasteful and all-around negative for the economy aside from all the bullshit work of the cartel employees directly providing them income. The room for efficiency improvements are, in this case, nearly the entire REVENUE of the middle-men, minus only the costs of the goods themselves, not just their profits!!

Insurance companies do TONS of bullshit economic waste that is both necessary to the system as it is today yet unnecessary in a single-payer system. All of that waste is NOT profit but IS available margin for efficiency improvements.

But really, insurers are just one aspect. There's also total craziness in the core pricing that providers set and lots of other complete insanity in the status quo.

P.S. the middle-man issues described above are potential market-failures for any market system and just one of many reasons that dogmatic "free market" ideology is bullshit. That said, there's cases where actions to fix market failures only make things worse. Recognizing that free-market dogma is bullshit does NOT mean the opposing dogma is correct.

Our current system is seriously inefficient. Look at how much we spend compared to similar industrialized countries that have single-payer systems. These numbers include the ~13% of the population that didn't have health insurance at the time this chart was created. So we currently pay roughly twice as much to cover 87% of our population. If we had a system similar to Germany we could do it with $600/capita/year in private money added. I would gladly split an additional $50/month in healthcare costs with my employer.