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>> anti-science stuff that gets thrown around these days It wasn't just anti-science but deliberate attempts to stop Obamacare, the ONLY initiative ever attemp

>> anti-science stuff that gets thrown around these days It wasn't just anti-science but deliberate attempts to stop Obamacare, the ONLY initiative ever attempted to fix the US healthcare system. Then came the Republicans to stop it. https://www.heritage.org/health-care-reform/commentary/why-trumps-executive-order-health-care-positive-step https://www.heritage.org/health-care-reform/commentary/why-t... IMO, the Pacific coast states need to reject national health care, create a health-care pact between states that slowly grows larger by adding new states. If another state doesn't want to join, then, so be it. Enough of splintered policies that change across state lines. Reduce health care insurance costs by allowing continued and universal care to states that elect this policy. The strength of change is in the states themselves, not the federal level. https://www.gov.ca.gov/2020/04/13/california-oregon-washington-announce-western-states-pact/ https://www.gov.ca.gov/2020/04/13/california-oregon-washingt...

rayiner 4y ago
> IMO, the Pacific coast states need to reject national health care, create a health-care pact between states that slowly grows larger by adding new states. If another state doesn't want to join, then, so be it. It blows my mind that they don’t do this. During most of the 20th century, Democrat-run states wanted to tax Republican California to pay for social programs. So doing things at the national level was critical. But now that the states that have all the money are also run by Democrats, that roadblock is gone. California can just tax California to pay for universal healthcare for California. They have no reason to care what Iowa chooses to do.
- tptacek 4y ago
  How do you avoid the obvious adverse selection problem? California can't prevent the most expensive people in the country from moving there, and the system we're talking about would be a powerful incentive for those people to do so.
  - bhupy 4y ago
    I think you're overstating just how "obvious" this adverse selection problem is, because we haven't seen this play out historically. It sounds like a purely theoretical problem. Canada established its single payer system provincially, one-by-one, and they didn't have this adverse selection problem. Saskatchewan was the first Province to offer single payer in 1947, followed by Alberta in 1951, etc. By 1961, all Provinces had some form of a single payer healthcare system. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110239/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110239/ > Taxpayer-funded medicare in Canada did not appear at a single point in time: it emerged over a quarter century from 1962, when physician services were covered across Saskatchewan, to 1987, when the demise of optional “full billing” in Ontario began. So at any given point in time between 1962 and 1987, there was (in theory) this adverse selection problem among certain provinces; and yet that was never really a major problem in Canada. Even to this day, the Canada Health Transfer which provides block funding to Provinces by the Federal government for the purpose of funding these single payer systems covers ~22% of the cost (https://www.cmaj.ca/content/192/45/E1408 https://www.cmaj.ca/content/192/45/E1408). Additionally, even in present day, the European Union has open borders and free immigration between member states, and certain member states have far more generous welfare systems than others, and you still don't have this adverse selection problem, at least in a manner that meaningfully renders those welfare systems unsustainable. Even domestically, we didn't really see dramatic net migration from states that refused to take the Medicaid expansion to those that did. The reality is that people don't choose where to live strictly on the basis of which state provides taxpayer funded healthcare. In fact, those that are most likely to do that (poor people) are likely already covered by Medicaid or heavily subsidized ACA plans (https://www.kff.org/policy-watch/millions-of-uninsured-americans-are-eligible-for-free-aca-health-insurance/ https://www.kff.org/policy-watch/millions-of-uninsured-ameri...). And even if one were to engage with the purely theoretical problem, there are ways to mitigate the adverse selection, e.g. by requiring a minimum number of years of residency in order to qualify. This is what US States do today to establish residency for the purpose of in-state university tuition. Given the plethora of historical (and current) data points that suggests that this isn't really a problem, States can choose to cross that bridge if/when they get there.
    - 4y ago
- fragmede 4y ago
  That's a good idea! Unfortunately, California is subject to the same business interests that the Federal government is also beholden to, so attempts to do so have a hard time getting traction for the exactly the same reason. https://www.npr.org/2022/01/31/1077155345/california-universal-health-care-bill-dies-without-a-vote https://www.npr.org/2022/01/31/1077155345/california-univers...
- lotsofpulp 4y ago
  Vermont did try it. https://en.wikipedia.org/wiki/Vermont_health_care_reform https://en.wikipedia.org/wiki/Vermont_health_care_reform It does not work for the reasons tptacek wrote. With freedom of movement, eventually net benefit recipients will move in, and net payers into the system will move out.
  - xyzzyz 4y ago
    Adverse selection is not at all why Vermont rolled back their decision.
  - ciphol 4y ago
    Vermont (a tiny state) would suffer much more from that than would California.
    - lotsofpulp 4y ago
      If I was a politician in any other state, I would propose exporting high cost patients to California by buying or subsidizing their housing. It is always the same story with any broad high cost universal benefit offered within a taxing jurisdiction that does not have immigration control. Homelessness (land costs), mental healthcare (legal and labor costs), and healthcare. Even subsidized higher education is not universal, it is restricted to residents. That is why we do not see these offered anywhere, and why it has to be a federal move.
  - rayiner 4y ago
    I don’t see evidence of that. Vermont grew slower than the country as a whole over the last decade, so it’s not like there was an influx of new residents. It sounds like people in Vermont just wouldn’t put their money where their mouth is and pay the taxes required for universal healthcare. Our German au pair paid almost 40% on her entry level office job. If you want universal healthcare like the Europeans well that’s what it costs.

rayiner 4y ago

> IMO, the Pacific coast states need to reject national health care, create a health-care pact between states that slowly grows larger by adding new states. If another state doesn't want to join, then, so be it. It blows my mind that they don’t do this. During most of the 20th century, Democrat-run states wanted to tax Republican California to pay for social programs. So doing things at the national level was critical. But now that the states that have all the money are also run by Democrats, that roadblock is gone. California can just tax California to pay for universal healthcare for California. They have no reason to care what Iowa chooses to do.

tptacek 4y ago
How do you avoid the obvious adverse selection problem? California can't prevent the most expensive people in the country from moving there, and the system we're talking about would be a powerful incentive for those people to do so.
- bhupy 4y ago
  I think you're overstating just how "obvious" this adverse selection problem is, because we haven't seen this play out historically. It sounds like a purely theoretical problem. Canada established its single payer system provincially, one-by-one, and they didn't have this adverse selection problem. Saskatchewan was the first Province to offer single payer in 1947, followed by Alberta in 1951, etc. By 1961, all Provinces had some form of a single payer healthcare system. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110239/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110239/ > Taxpayer-funded medicare in Canada did not appear at a single point in time: it emerged over a quarter century from 1962, when physician services were covered across Saskatchewan, to 1987, when the demise of optional “full billing” in Ontario began. So at any given point in time between 1962 and 1987, there was (in theory) this adverse selection problem among certain provinces; and yet that was never really a major problem in Canada. Even to this day, the Canada Health Transfer which provides block funding to Provinces by the Federal government for the purpose of funding these single payer systems covers ~22% of the cost (https://www.cmaj.ca/content/192/45/E1408 https://www.cmaj.ca/content/192/45/E1408). Additionally, even in present day, the European Union has open borders and free immigration between member states, and certain member states have far more generous welfare systems than others, and you still don't have this adverse selection problem, at least in a manner that meaningfully renders those welfare systems unsustainable. Even domestically, we didn't really see dramatic net migration from states that refused to take the Medicaid expansion to those that did. The reality is that people don't choose where to live strictly on the basis of which state provides taxpayer funded healthcare. In fact, those that are most likely to do that (poor people) are likely already covered by Medicaid or heavily subsidized ACA plans (https://www.kff.org/policy-watch/millions-of-uninsured-americans-are-eligible-for-free-aca-health-insurance/ https://www.kff.org/policy-watch/millions-of-uninsured-ameri...). And even if one were to engage with the purely theoretical problem, there are ways to mitigate the adverse selection, e.g. by requiring a minimum number of years of residency in order to qualify. This is what US States do today to establish residency for the purpose of in-state university tuition. Given the plethora of historical (and current) data points that suggests that this isn't really a problem, States can choose to cross that bridge if/when they get there.
  - 4y ago
fragmede 4y ago
That's a good idea! Unfortunately, California is subject to the same business interests that the Federal government is also beholden to, so attempts to do so have a hard time getting traction for the exactly the same reason. https://www.npr.org/2022/01/31/1077155345/california-universal-health-care-bill-dies-without-a-vote https://www.npr.org/2022/01/31/1077155345/california-univers...
lotsofpulp 4y ago
Vermont did try it. https://en.wikipedia.org/wiki/Vermont_health_care_reform https://en.wikipedia.org/wiki/Vermont_health_care_reform It does not work for the reasons tptacek wrote. With freedom of movement, eventually net benefit recipients will move in, and net payers into the system will move out.
- xyzzyz 4y ago
  Adverse selection is not at all why Vermont rolled back their decision.
- ciphol 4y ago
  Vermont (a tiny state) would suffer much more from that than would California.
  - lotsofpulp 4y ago
    If I was a politician in any other state, I would propose exporting high cost patients to California by buying or subsidizing their housing. It is always the same story with any broad high cost universal benefit offered within a taxing jurisdiction that does not have immigration control. Homelessness (land costs), mental healthcare (legal and labor costs), and healthcare. Even subsidized higher education is not universal, it is restricted to residents. That is why we do not see these offered anywhere, and why it has to be a federal move.
- rayiner 4y ago
  I don’t see evidence of that. Vermont grew slower than the country as a whole over the last decade, so it’s not like there was an influx of new residents. It sounds like people in Vermont just wouldn’t put their money where their mouth is and pay the taxes required for universal healthcare. Our German au pair paid almost 40% on her entry level office job. If you want universal healthcare like the Europeans well that’s what it costs.