Universal healthcare, say Medicare for All style, does not have to mean higher taxes. And it would make a big difference to gig workers and the ones working for the likes of Walmart.

A very high percentage of Walmart employees need government assistance due to their income not actually being enough to pay the laborer what their labor costs them to deliver.

At a minimum, labor needs to exist reasonably and show up for work. Healthcare is a part of that, right along with the basics.

All of us are subsidizing labor for a few of us to put profit, or more peak profit in the bank.

The priority discussion boils down to what makes the most sense for the nation.

Do we cut back on the military industrial complex?

Maybe we decide subsidizing labor makes sense. That would also mean not shaming and blaming people who seek and obtain help from the government. Doing that is baked in right now, in that no matter what those people do, a large percentage of them will need help.

Or, we simply change nothing and yes, taxes are higher, but the national spend is lower overall. Many of us will benefit.

We could prioritize it so employers are more on the hook in various ways. Some of them will not be viable. Even if they all are, we may not have enough jobs. Government could be an employer to make sure everyone has a work opportunity that pays enough to exist and show up for work.

There are many options. Not all mean higher taxes, but all that discussion means a national priority talk also has to happen.

If we do nothing, our priority is not having people make it, exist reasonably and show up for work.

Predictably, lots of people are not making it, may do crime, are homeless, may not have health care, maybe will show up for work, if they can get it.

If our priority becomes about people existing reasonably and showing up for work, we will see that, but will have higher taxes, or back off some other things we currently make a priority.

The US spends $676 billion on defense, almost the exact same amount on Medicare, $1 trillion on Social Security, and $409 billion on Medicaid. Social welfare spending is a much, much larger portion of the US budget than military spending. Here are the numbers straight from the Congressional Budget Office https://www.cbo.gov/system/files/2020-04/56324-CBO-2019-budg...

Did that Trillion not come from people contributing? You know it did.

And still, we can and should totally question our current spend.

How does that impact the discussion? Do we think we need another problem by not actually paying those benefits?

Secondly, back to the first question, so?

What's our priority?

Right now that priority is not healthy people, able to show up for work, existing reasonably.

Does that make the best sense? I don't think so.

The other thing I did was walkthrough a little bit about what those priorities might look like. There's several ways to solve this problem.

And we do have a problem when roughly half the labor force makes roughly 30k a year.

How would that be? It seems like it certainly would to me. Maybe by less than employees plus employers currently pay in aggregate healthcare costs, but I can't imagine a way where the government pays for Medicare-for-all and taxes don't go up.

Do you have a specific idea in mind that I'm missing?

In short - you can buy a banana for a dime or give the government a nickle and get a "free" banana.

I'm super glad my mom has Medicare! But she isn't benefitting from it being efficient, she's benefitting from it setting the rate it pays and requiring providers to accept it.

The other is a compulsory payment to a government entity as a result of earning income.

The rest of the developed world would very strongly disagree.

The penalty for not making that payment can be death, is likely financial ruin.

For many people, that optional payment is enough to buy a home.

Ask around about "optional"

Then we can set that aside and recognize net, liquid income will go up for most everyone.

All in the US more or less pays roughly 2x or more what some other countries pay for equivalent healthcare, so there is nominally room to extend coverage while keeping costs flat in theory. In practice, it's complicated. Also 'roughly' and 'more or less' have some wiggle room for systemic differences, but it's about right.

The obvious solutions include new hybrid classifications or mandating certain benefits based on tenure. Why is this not considered? Why take away choice from those who specifically decided not to get a full-time driving job (which have always existed)?

I think a more productive line of debate would be:

1. Do we, as a society, believe we should only care for those who can be productive?

2. Do we, as a society, value things other than productivity?

3. Do we, as a society, believe it is the place of a governing body to ensure a standard quality of life (whatever that standard may be)?

Putting barriers around who deserves what doesn't really serve to do much other than exclude people who don't know how to work the system, or those who are unable to work the system.

In some countries these decisions are made for you and funded through taxes and fees. Other nations require you to plan your own way. The USA leans toward the individual over the state.

Certain things like healthcare should be revamped to remove the ties to employers but it's important to keep the prevailing culture in mind. People overwhelmingly still want the ability to choose here - what they lack are the options to choose from.

As an example my grandfather lost his leg to a blood clot due to being sent to an overwhelmed hospital that left him sitting undiagnosed for hours on end - it is easy to read that scenario as being forced into a lack of care, but choices wouldn't help things here. If he had a choice he would have advocated for going to his family doctor first which would have made the situation worse - in all honestly hospital overcrowding and underfunding is the only thing that led to him losing his leg.

Healthcare is a sector of the market that most people here (even me - and I work in a company that deals specifically in the US healthcare market) don't have enough knowledge to make intelligent choices in because the knowledge needed to comprehend all the random crap that can go wrong with your body is intensely deep.

I also don't think it's far to say the US favors individuals over the state - the US cares very little about individual health. And that's not precisely what you meant when you said it favors individuals over the state but I think it's important to highlight that the situation in the USA is quite detrimental to a lot of individuals.

And yes, I do want to choose my healthcare. I want to select the plan that best fits my needs. If you want a larger simpler plan that covers everything then you can choose that.

Me having choice does not take away from you, it only provides more for both of us.

And I especially don't understand how it doesn't lead to exactly the problematic outcome we are talking about which is that poor people can't afford access to quality healthcare.

You don't "choose" what level of fire department protection you need. How is healthcare different? I suppose you can always hire your own private firefighter/doctor...

So long as you give people the choice, and it's based on PERSONAL financial contributions rather than government-organized taxes, those with less means will have less access to a finite set of healthcare resources and result in systemic inequalities.

I suppose I can imagine that there is some "ultra deluxe" version of healthcare where instead of crutches you get a wheelchair, and instead of a shared recovery room you get your own, and I do support those with the means to pay extra for something like that. But the baseline HEALTHCARE access part needs to remain the same...

The issue is that better coverage requires private insurance, mostly offered through corporations. Smaller companies can't compete, some people can't leave a bad job because of losing their plan, and others are limited to public options because they don't work. This is the overwhelming problem with USA healthcare. There aren't actually many choices because of this complex and outdated connection between jobs and benefits.

I know that today America has choice. But it leads to the highest healthcare costs in the Western World (to allow for middlemen healthcare companies to be some of the largest privatecompanies in the country), with the worst quality for the poorest people.

So the question is, how do you solve the problem of universal access while giving people the "choice".

> The issue is that better coverage requires private insurance, mostly offered through corporations

Not in the rest of the western world. We just simply don't have these companies. They don't need to exist. They are a form of corporate socialism transferring wealth from taxpayers to mediate something that can be handled directly.

Health insurance companies is a moral failure. I'm going to double down on my metaphor. Fire engines don't check your insurance to decide if they should put your fire out. That used to be how things worked 100 years ago.

The choice for better healthcare is limited and locked behind employment. That's the problem, instead of letting everyone have access to all plans, and the solutions are too complicated to discuss here. However insurance is not a moral failure, it's a financial and risk management concept. Just because your government manages somethings for you with your taxes doesn't mean it doesn't exist.

I understand that when you're a fish it's hard to understand what water is, but the fact that employment plays any part into this whatsoever is a problem. Nobody in Canada or the UK or Luxembourg (some countries i have some experience with) would ever factor in healthcare in a decision to start or leave a job. It is absolutely not a variable.

Yes, I've said exactly this about half a dozen times now. It seems you're arguing based on myths and preconceived notions against the USA rather than actually responding to anything I've said. Let's end it here.

I just don't understand you acknowledging that healthcare choice being locked behind employment and insurance companies middlemen being a problem yet still wanting "healthcare choice." What does that mean to you if you don't have the others any longer?

I absolutely want to choose my healthcare.

The choice being discussed here is specifically around health plan particulars like stronger vs. weaker drug covers - surprising you by not covering any oncological drugs - or having a different balance between deductible and cost.

I'm still trying to grip why people care about choice though since most of those become non-issues with national insurance - most of those choices are about how you're going to balance paying for care with limited resources, while in nationalized systems the question of cost is mostly or fully removed - it's just the auxiliary costs that still can bite you (i.e. parking costs at a hospital, costs for a private room for recovery, etc...)

People have preferences for different doctors. Choosing different doctors is part of choosing your healthcare. Personally, I order my own tests and come to doctors with recommendations and ideas to discuss. Not all of them are open to this collaborative approach.

In terms of choosing insurance... It's a little silly to talk about what people want. What many people want is to go to whatever doctor or hospital whenever they want and have someone else pay for it. They often foolishly choose to limit out of pocket costs at point of service, while paying for coverage they don't need. Different people have different concerns. My preference is for my insurance to be for when I need it, and "first dollar coverage" is insuring me for an expense I can already afford, making it a bad deal.

To me the "prevailing culture" is more about the vibrancy of walking into a vendor and directly paying for services that you would like, rather than needing to appeal to some bureaucracy (whether "public" or "private") to convince it to agree that you "need" something. The medical system is currently so far from this, that I don't think it has much bearing on the practical reforms being discussed. Although I would love to see reforms in this direction as well - eg published price lists uniform for any payer, and a prohibition on arbitrary post-facto billing.

It's more like the providers have to conform to the Medicare pricing, instead of screwing the payers. This is why we need single pricer. Simply put into Medicare pricing agreements that the provider cannot charge anyone more than they charge Medicare or Medicaid. Not only does it avoid the price gouging of the uninsured and privately insured, it also ends the whole concept of out of network. Very few providers can survive without Medicare funds.

Politically I wonder what's holding this back, as it seems like it would be more palatable than Medicare for all. Silent hospital lobby? Big insurers that don't actually want to make their market more efficient as they're effectively cost-plus entities?

Not balancing this means society will go into decline one way or the other.

Offering basic levels to society members is health if the society can afford it and allows the society to grow quickie because risk is removed.

This is overly simplistic. Someone providing child or elder care is providing social value in a way which should not be measured against economic measures of production. Life is not an economic zero-sum game.

You might "work" 2h a month, because you spend the rest of it caring for family members, or maybe you're trying to get that first draft/beta version out the door.

Or you might just not want to work.

We need to stop assigning so much worth to work. We know automation is coming, and we know that not everyone is going to be able to find work in the future.

I mean it as a serious question, as it's not clear to me what the difference between benefits and salary is (not being from US).

I understand that the health insurance is one of them (and, to be clear, I do believe you should have that whether you work 0 or 100 hours a month).

But what are others? Pension contribution is just a part of your salary that you are required by law to put aside. Guaranteed minimum time off comes to mind, but that obviously makes less sense if you are already not working too much. What else?

There are millions of employees in the US who work part-time and choose their own schedules.

They do not allow you the same flexibility to work for the next 30 minutes, take a few hours off, then work another hour this evening without doing anything more than just starting or stopping the app whenever you feel like.

How would you replicate that with part-time hours?

This is a silly argument. You pay for your healthcare no matter what, it's just a question of who administers it.

> Then you put a million exclusions and tax deductions and other loopholes, so no one knows what they're really getting

This is precisely the current state of employer-sponsored healthcare, and also the wildly complicated medicare/medicaid system.

Universal coverage combined with higher taxes (ideally on people who already have lots of money and therefore place very little value on marginal income) is arguably better and easier to reason about than a mandate for employer-provided coverage and its associated opaque and complicated effects on labor markets, including higher fixed costs of hiring people and decreased ability for people to move between regions, industries, and even jobs within the same industry/career.

But who administers it has a lot to do with how much you pay for it. For example, a high deductible plan will save you a lot of money as long as you aren't in the 99th percentile of healthcare needs, and (unless the deductible is really high) still not bankrupt you if it turns out you are.

Any kind of government plan that doesn't give you that choice because it's paid from taxes rather than premiums is plausibly going to cost you more money. And that's true even on average, because high deductible plans make people more price sensitive, which exerts downward pressure on costs. (The fact that US healthcare regulations disfavor high deductible plans is one of the reasons costs remain high.)

The US system is also uniquely screwed because the rest of the world piggybacks on US medical R&D while in practice regulating prices even for products under patent. The result is that the US market is paying a disproportionate share of the R&D cost. Cost comparisons to single payer systems that pretend that single payer systems are inherently less expensive are ignoring the lower contribution of those systems to worldwide medical R&D. Moreover, the recipient companies are disproportionately in the US and have lobbyists and large numbers of voter-employees, so implementing a single payer system here would be unlikely to remove those costs. Then you're left with the resulting increase in price insensitivity and the US system becomes even more unaffordable.

It's actually a hard problem. The solution probably has to involve the other countries paying more of the R&D.

I'm happy to talk about manufacturer drug rebates which is an amazingly crazy portion of the healthcare market that would be illegal in almost any other market due to the perverse market incentives it creates. But yea, the short version is that the private healthcare market is incredibly inefficient.

"We" don't necessarily think benefits should be provided by the whims of private businesses.

as opposed to the government because that means higher taxes.

The assumption here being that benefits from the government are paid with higher taxes, and benefits from employers being paid from the kindness of the CEO's heart and not from wages that would have otherwise been paid you.

>"We" don't

I want the money that my employer pays into health insurance to be paid to me into an HSA like tax sheltering of healthcare funds, and then I want no health insurance middleman. Poof---there goes all the corrupt incentives and ridiculous administrative overhead.

That is literally impossible. Even if insurance companies are made illegal tomorrow, that role of market maker between providers (doctors and hospitals, drug companies) and customers (patients, employers) will always exist. This is because such a role is needed.

Patients do not have the capacity nor the knowledge to find the best doctor, the best hospital, or the best drug maker for them.

Health insurance was invented in the late 1930s as a political ploy to forestall government health programs. Did patients all get stupid at that time, or was it the case that they were all going to the wrong doctors and hospitals before then?

Please give human beings a little credit. We make decisions every day, some of which are a lot more substantial than which state-licensed physician to hire.

ps. you don't know what "market maker" means...

Okay, but I didn't mean literally outlaw insurance middlemen.

I mean fix the incentive structure such that I have the option to forego insurance middlemen.

> Patients do not have the capacity nor the knowledge

I completely disagree, and what business of yours or anyone's is it to say I'm `lacking in capacity and knowledge` to such a degree I shouldn't be allowed to make my own healthcare decisions!?

Worse still, right now the US government puts a cap on the percentage of profit an insurance company can take from premiums which coupled with the current near monopolistic healthcare insurance system incentivizes paying as much as possible for treatment to justify higher premiums.

And what defines a good quality of life depends on who you ask.

I have a chronic condition and for a year the only reason family didn’t end up on street is because of gig jobs. Most days 12-16 hours a day in bed essentially blind in horrific pain. But sometimes totally fine. Disability straight up laughed at me.

Ironically this completely flies in the face of any motion or ‘diversity and inclusion’.

At a certain point I had to stop going to the doctor so I would be able to get enough hours in keep keep the house.

What is 'decent housing' for instance? An apartment in the affordable part of town, shared with 3 room-mates? Your own condo? Your own house in the suburbs? A home in a gated community?

Is 'decent food' the minimum amount of recommended nutrition as defined by the USDA? Or eating out 3 nights a week? Or enjoying prime rib whenever you feel like it?

Is "decent healthcare" a checkup every year? Or a Cadillac insurance plan?

Any combination of these could be called an acceptable standard of living depending on who you ask. It's totally subjective, but the difference between them is tens of thousands of dollars a year.

And how do you define those? I've heard people on here complain that $200k isn't enough for a good life with a family. Yet I make less than half that and pay all the bills for my family. Clearly standard of living and cost of living can have a huge fluctuations on location and what one thinks they are entitled to under a decent life.

For example, a studio apartment in a bad school district might be decent for a single person with no kids. Yet that likely would not meet the definition of decent for a family of 4. Unless, that was a step up from wherever you were living before (maybe on the street). Some people might say they have to eat out or have steaks to have decent food. But others might just want a discount grocery story with freash fruits and veggies with off-brand staples to meet their criteria of decent.

It all depends on people's expectations and needs.

They basically make money buying and selling items occasionally, when they see a deal. That's enough for them to buy all the "luxuries" they want ($5k car, $2k laptop) every couple years.

I think there's a big difference between peoples desires/definition of acceptable and what they put in to obtain them.

And then that's just talking about the structure. What about the location - if a person's entire support system is in one location but the available free housing is 75 miles away and they don't have a car, that isn't decent. This comes up all the time re the affordability of the Bay Area where locals get priced out, someone says "just move to stockton" and the resident feels it's not fair (or "decent") to have to leave where they were born and raised.

You could link location to workplace I suppose but then that would create massive downward pressure on wages since people would be willing to sacrifice pay in order to live where they prefer. This sounds like a net negative.

This question is only hard if you haven't thought about it for more than like 2 seconds.

I can't believe I'm spelling this out. A person picking out their ideal home has trouble figuring out exactly what they want. Ok. We all don't ever know exactly what we want. It's the human condition. But I don't want to live in grinding poverty. I don't need to look within to figure that one out.

I don't want my home to be dilapidated, overcrowded, full of pests and toxins, or to not exist.

If you're still pretending to have a hard time with the definition of "decent," consult a dictionary.

This line of argument is absurd word chopping. "Oh my, I could never in good conscience try to lock down a subtle word like 'decent' into a singular meaning, guess drivers will have to stay earning a sub-living wage forever. Sorry! Definitions are hard!"

No.

What I am arguing against is your baseless assertion that defining "decent housing" is easy, and that everyone who thinks it's hard is simply being obstructionist/anti-poor/whatever.

The closest thing we might have today to an across-the-board definition of "decent housing" might be HUD's FHA standards which -- to your shock and amazement, I assume -- is much more complex than "must be decent"

The current structure treats them as serfs and says what really matters is the efficiency of the overall system, or its ability to generate a profit for its shareholders, or whatever. In short, the problem is these guys work too much in exchange for too little. Whatever theories anybody might have about the market, the role of the state in the market, etc, those are the basic facts on the ground: over-exploited workers seeking dignity where they currently lack it. The idea that they are "contractors," in the way that you or I might be contractors sometimes (I assume you are a tech worker), as experts in a technical field, is a sick joke. They don't have any power to get what they need, in that market, as individuals (they aren't even allowed to set their own prices!). If they could bargain collectively, they might. That's the context here.

When somebody enters the discussion and says, "Well, yeah, but what IS dignity, anyway, when you really think about it, man???" you'll have to forgive me if I don't believe they're doing it out of a devotion to clarifying terms but because they just want to take Uber's side in the fight. Yes, it's obscurantism.

In deeply complex and high-stakes systems, the details matter a lot; I haven't thought about it too deeply but my intuition says that they're the only thing that matters. Unintended consequences (like my salary depression example above) need to be carefully considered. There is inherent inequality built into a naive system like you suggest: an apartment in SF is worth multiples of an apartment in OK, are we alright with that? (don't answer, just an example). The details and their impact are important.

Some –certainly not all– have taken it a step further and offer pharmacare, daycare, a livable minimum wage, and free higher education.

Still, worldwide, there's an uneven or inequitable provision of other basics, such as disability benefits, guaranteed housing, food, and internet access. All of which I would argue is even more necessary for a good quality of life for all.

I don’t want to be chained to my employer for benefits, for retirement, for healthcare. It’s stupid to put a sociopathic entity with no accountability to you in charge of your basic needs.

Just look at how the city of Flint, MI poisoned their own citizens water while suppressing knowledge of their actions. [0] While in the grand scheme of government atrocities this actually appears relatively minor, this issue happened in very recent times.

One could fill pages listing government atrocities before even getting to basic incompetence and mismanagement. While inefficiencies happen in all bureaucratic organizations, governments hold singular power over their citizens in a way that no corporation could ever dream of.

This is not an argument against government. There are some services that only the government can provide. E.g., a strong military. Nor is this an argument against government playing some role in promoting general welfare.

I just personally would like the option to not be further dependent upon our government and would rather use my own economic agency to provide for my own unique needs. Many other people feel similarly and therefore reject this further intrusion of government in dictating our labor relations with employers.

[0] https://en.wikipedia.org/wiki/Flint_water_crisis

I guess I don’t understand why this is the line in the sand, and why we must depend on private profit-motive entities to provide for basic welfare and an economic safety net when we can see it working in developed countries around the world.

Everyone choosing what is exactly right for them implies those choices are all possible and the complexity, risk and cost profile also makes sense.

Those things are not true, and the outcome is rapidly escalating cost and risk exposure.

This has been addressed in many ways, and one of the easier ways is to have government fund those bennies to provide a respectable floor. People who need more can choose to do that and the market for such things would make much more sense and be lower cost and risk for everyone.

An example seen worldwide is supplemental plans that operate in addition to primary plans, which are actually illegal in many parts of the world due to the inherent conflict between profit motive and health care.

You wanting to keep your money and make choices is very different from wanting other people to keep their money, which is an overreach frankly.

Further, in the current scenario, you really can't be sure medical people have your best interests in mind because the priority is making money not making sure we have healthy people.

When medical people are free to actually make healthy people a priority, the discussion about best interests becomes a much easier one.

Rough state of affairs, I would imagine.

However, I am far from unique.