7 ms·

What's to stop your local city government from increasing taxes to hire a doctor and provide them with a building and staff in order to provide medical services

What's to stop your local city government from increasing taxes to hire a doctor and provide them with a building and staff in order to provide medical services to locals residents? It seems to me that the problem is that everyone wants a federal solution to healthcare and the United States is generally structured to limit federal power. Fire departments are funded locally generally speaking, it didn't take a federal mandate to create them. If you think medical services should be provided to people as a civic service, go convince your local government to do it.

toomuchtodo 3y ago
https://www.actuary.org/sites/default/files/pdf/health/pool_july09.pdf https://www.actuary.org/sites/default/files/pdf/health/pool_... ("For a risk pool to remain viable, it must be of sufficient size and comprised of a broad cross section of risks.")
- sokoloff 3y ago
  There are US states more populous than some European countries. Maybe a city can’t do it, but plenty of states could. It’s just damn expensive to try.
  - muttled 3y ago
    Reading your comment, I had the thought "I wonder if California's done it?" Turns out they've tried it 10 times. I'd imagine there's a lot of money being thrown against the initiative by for-profit insurance companies, which is an industry with a lot of cash to buy laws. https://stateofreform.com/featured/2023/05/california-seeks-to-establish-single-payer-healthcare-system-for-10th-time-since-1994/ https://stateofreform.com/featured/2023/05/california-seeks-...
    - sokoloff 3y ago
      That reads like they've tried to try it 9 or 10 times. They haven't even gotten to the point of finding out what all might turn out differently in a US state than in an EU country surrounded by other EU countries, all with roughly similar approaches to public health care.
      - cmh89 3y ago
        I work in public health at a state government, in a western state. The biggest hurdle I see is that America has freedom of movement and residency. If my state creates truly affordable health care, we will of course have refugees from conservative states coming here for medical care. We'll probably end up with a public option of some kind that will somewhat function like health insurance but who knows.
        bravura 3y ago
        This is an interesting point. And perhaps worse yet, high quality doctors will have the freedom to move out of your state. I'm an American living and Germany and sadly, my GP who is also a personal friend of mine, will be shutting down their practice at the end of the year because their small practice simply isn't financially sustainable. They will instead start treating the prison population, which apparently pays more / is more consistent. So I can also imagine how doctors in your state would feel if suddenly their rates are dramatically capped by the state. I'm not aware of any public health care systems where medical care services are as expensive as in the United States, but perhaps it's possible to maintain relatively similar doctor pay as currently exists AND provide socialized health care benefits. I really don't know enough about this topic and the financials of American (non-public) health insurance companies to comment accurately on whether that would be feasible.
        cmh89 3y ago
        There is no chance that the state would cap rates, I'm not sure they even could. The real pull would be trying to expand Medicaid, which is free,creating a single payer system and raising taxes, or creating public health insurance, or some combination of both. The public option would be the best in a vacuum, but if its truly affordable, we will still attract uninsured and under-insured people who come here when they get sick.
        sharts 3y ago
        Prices could probably drop if the market was saturated with doctors. And the best way to do that would be eliminating medical-school debt.
    - outside1234 3y ago
      The problem with doing it at the state level is that then all the sick will move to that state. Which won’t work from a risk pool perspective
      - sharts 3y ago
        It would seem unlikely that all sick people would move just for one perk. Most people do not take moving as a light decision. Also most people that actually do move would likely have jobs with taxable wages that helps to subsidize things. The real risk population is maybe the homeless sick that migrate. But those tend to be in a different category entirely (e.g mental illness, addiction, trafficking etc.)
        StockHuman 3y ago
        Well sharts, most people don’t take dying too lightly either. Free care for the gravely infirm would be, to a point, the only perk that mattered at the exclusion of all others. Likewise with the possibility of total bankruptcy.
        dfadsadsf 3y ago
        This problems is mostly solved for in state vs out of state tuition. Just institute 12-15 month waiting period or 3 months waiting period with full time job.
ceejayoz 3y ago
Mainly, that one city or state doing it will likely cause an influx of sicker people. You can't require a visa to come to, say, Austin TX, and "only to residents who've lived here longer than x" would raise equal protection constitutional issues. (This is the same reason the ACA had the individual mandate, and why said mandate's striking down is likely to result in the ACA's failure or needing significant amending soon.)
- telotortium 3y ago
  > "only to residents who've lived here longer than x" would raise equal protection constitutional issues States seem to apply residency consideration all the time to college tuition and taxes, among others. Why would equal protection be an issue here? Austin, TX can't implement this on its own without state support, but cities don't have any federal constitutional rights apart from their containing states, so that's too bad
  - ceejayoz 3y ago
    > States seem to apply residency consideration all the time to college tuition and taxes, among others. Why would equal protection be an issue here? Because you're either going to have to pick some fairly short period of time - a year or less - which won't be that much of an obstacle to folks seeking healthcare (especially if private healthcare remains available in that interim period), or you'll run afoul of Zobel v. Williams if you try to make a permanent or long-lived distinction.
    - telotortium 3y ago
      Yes, that is a trade-off.
    - ipaddr 3y ago
      You structure it as paying into a plan. For each year lived in the state you get 20% coverage (upto 5 years) which would smooth out the cost and provide fairness to poorer local residents.
Modified3019 3y ago
Do you count the influx of homeless as residents? These people absolutely need healthcare, but they are a resource drain that can move in suddenly, unpredictably, and overwhelm a local solution with static resources. Then you get a situation where the wealthy, even (and sometimes especially) the diehard leftists who voted for the situation, turn up their nose at what’s shown up in their backyard, and fuck off from California to Colorado or Texas. This reduces the tax resource pool, stressing the residents and businesses that can’t afford to leave further. This creates resentment. Coupled with the overly dramatic and personal shitshow that is local politics, frankly I see local initiatives as a fantastic way to fail tens of thousands of times. Fixes have to take place at least at the state level, and even that is less than ideal, because expenses have to be spread out (especially in regards to the wealthiest 1% that pay a huge chunk of income tax, and are not equally distributed across local towns) without creating an attractive hotspots for tax resource competition.
- thebradbain 3y ago
  Except the only demographic of net in-flow _moving to California_ are those in the top 5% or so. https://www.latimes.com/politics/la-pol-sac-skelton-income-tax-california-wealthy-20190311-story.html https://www.latimes.com/politics/la-pol-sac-skelton-income-t... Note: this article is from 2019, which is obviously pre-Covid. I still think it’s too early to predict any trend on post-Covid migrations (which would really be captured and 2022-2023 and 2023-2024, assuming you started planning to leave mid-pandemic 2021-2022) California had its largest tax surplus in the history of a state ever the 2022 fiscal year.
  - Modified3019 3y ago
    FYI, unless they fix their tax system, they are currently headed towards a (last I checked) 30+ billion dollar deficit this year. They also recently raised taxes on income over (I think) $1 million again last year, and I believe plan to continue to do so. Also for a more up to date perspective on migration and money: https://calmatters.org/commentary/2022/08/california-is-leaking-vital-high-income-taxpayers/ https://calmatters.org/commentary/2022/08/california-is-leak... https://www.sfchronicle.com/sf/article/San-Francisco-migration-17353393.php https://www.sfchronicle.com/sf/article/San-Francisco-migrati... Regardless, this still supports my point that state level healthcare while far more durable than local gov, still can’t compare to national level stability.
Amezarak 3y ago
Hospitals and public health systems owned and operated by city and county governments are not actually unusual in the US. They're fairly common.
dangus 3y ago
There really isn’t anything that constitutionally prevents the federal government from establishing universal healthcare. See Medicare and Medicaid.
lokar 3y ago
In the large, the issue is taxes are too low to support current spending. Only the federal government can run a sustained deficit. Republicans aggressively take advantage of this to cut taxes while disingenuously complaining about debt.
cabaalis 3y ago
I don't know about other states, but my state Tennessee and its counties do just this. I'd be willing to bet it's more common than not across the US. https://www.tn.gov/health/health-program-areas/localdepartments.html https://www.tn.gov/health/health-program-areas/localdepartme...
mbgerring 3y ago
San Francisco started doing something like this in 2007: https://en.m.wikipedia.org/wiki/Healthy_San_Francisco https://en.m.wikipedia.org/wiki/Healthy_San_Francisco

toomuchtodo 3y ago

https://www.actuary.org/sites/default/files/pdf/health/pool_july09.pdf https://www.actuary.org/sites/default/files/pdf/health/pool_... ("For a risk pool to remain viable, it must be of sufficient size and comprised of a broad cross section of risks.")

sokoloff 3y ago
There are US states more populous than some European countries. Maybe a city can’t do it, but plenty of states could. It’s just damn expensive to try.
- muttled 3y ago
  Reading your comment, I had the thought "I wonder if California's done it?" Turns out they've tried it 10 times. I'd imagine there's a lot of money being thrown against the initiative by for-profit insurance companies, which is an industry with a lot of cash to buy laws. https://stateofreform.com/featured/2023/05/california-seeks-to-establish-single-payer-healthcare-system-for-10th-time-since-1994/ https://stateofreform.com/featured/2023/05/california-seeks-...
  - sokoloff 3y ago
    That reads like they've tried to try it 9 or 10 times. They haven't even gotten to the point of finding out what all might turn out differently in a US state than in an EU country surrounded by other EU countries, all with roughly similar approaches to public health care.
    - cmh89 3y ago
      I work in public health at a state government, in a western state. The biggest hurdle I see is that America has freedom of movement and residency. If my state creates truly affordable health care, we will of course have refugees from conservative states coming here for medical care. We'll probably end up with a public option of some kind that will somewhat function like health insurance but who knows.
      - bravura 3y ago
        This is an interesting point. And perhaps worse yet, high quality doctors will have the freedom to move out of your state. I'm an American living and Germany and sadly, my GP who is also a personal friend of mine, will be shutting down their practice at the end of the year because their small practice simply isn't financially sustainable. They will instead start treating the prison population, which apparently pays more / is more consistent. So I can also imagine how doctors in your state would feel if suddenly their rates are dramatically capped by the state. I'm not aware of any public health care systems where medical care services are as expensive as in the United States, but perhaps it's possible to maintain relatively similar doctor pay as currently exists AND provide socialized health care benefits. I really don't know enough about this topic and the financials of American (non-public) health insurance companies to comment accurately on whether that would be feasible.
        cmh89 3y ago
        There is no chance that the state would cap rates, I'm not sure they even could. The real pull would be trying to expand Medicaid, which is free,creating a single payer system and raising taxes, or creating public health insurance, or some combination of both. The public option would be the best in a vacuum, but if its truly affordable, we will still attract uninsured and under-insured people who come here when they get sick.
        sharts 3y ago
        Prices could probably drop if the market was saturated with doctors. And the best way to do that would be eliminating medical-school debt.
  - outside1234 3y ago
    The problem with doing it at the state level is that then all the sick will move to that state. Which won’t work from a risk pool perspective
    - sharts 3y ago
      It would seem unlikely that all sick people would move just for one perk. Most people do not take moving as a light decision. Also most people that actually do move would likely have jobs with taxable wages that helps to subsidize things. The real risk population is maybe the homeless sick that migrate. But those tend to be in a different category entirely (e.g mental illness, addiction, trafficking etc.)
      - StockHuman 3y ago
        Well sharts, most people don’t take dying too lightly either. Free care for the gravely infirm would be, to a point, the only perk that mattered at the exclusion of all others. Likewise with the possibility of total bankruptcy.
        dfadsadsf 3y ago
        This problems is mostly solved for in state vs out of state tuition. Just institute 12-15 month waiting period or 3 months waiting period with full time job.

ceejayoz 3y ago

Mainly, that one city or state doing it will likely cause an influx of sicker people. You can't require a visa to come to, say, Austin TX, and "only to residents who've lived here longer than x" would raise equal protection constitutional issues. (This is the same reason the ACA had the individual mandate, and why said mandate's striking down is likely to result in the ACA's failure or needing significant amending soon.)

telotortium 3y ago
> "only to residents who've lived here longer than x" would raise equal protection constitutional issues States seem to apply residency consideration all the time to college tuition and taxes, among others. Why would equal protection be an issue here? Austin, TX can't implement this on its own without state support, but cities don't have any federal constitutional rights apart from their containing states, so that's too bad
- ceejayoz 3y ago
  > States seem to apply residency consideration all the time to college tuition and taxes, among others. Why would equal protection be an issue here? Because you're either going to have to pick some fairly short period of time - a year or less - which won't be that much of an obstacle to folks seeking healthcare (especially if private healthcare remains available in that interim period), or you'll run afoul of Zobel v. Williams if you try to make a permanent or long-lived distinction.
  - telotortium 3y ago
    Yes, that is a trade-off.
  - ipaddr 3y ago
    You structure it as paying into a plan. For each year lived in the state you get 20% coverage (upto 5 years) which would smooth out the cost and provide fairness to poorer local residents.

Modified3019 3y ago

Do you count the influx of homeless as residents? These people absolutely need healthcare, but they are a resource drain that can move in suddenly, unpredictably, and overwhelm a local solution with static resources. Then you get a situation where the wealthy, even (and sometimes especially) the diehard leftists who voted for the situation, turn up their nose at what’s shown up in their backyard, and fuck off from California to Colorado or Texas. This reduces the tax resource pool, stressing the residents and businesses that can’t afford to leave further. This creates resentment. Coupled with the overly dramatic and personal shitshow that is local politics, frankly I see local initiatives as a fantastic way to fail tens of thousands of times. Fixes have to take place at least at the state level, and even that is less than ideal, because expenses have to be spread out (especially in regards to the wealthiest 1% that pay a huge chunk of income tax, and are not equally distributed across local towns) without creating an attractive hotspots for tax resource competition.

thebradbain 3y ago
Except the only demographic of net in-flow _moving to California_ are those in the top 5% or so. https://www.latimes.com/politics/la-pol-sac-skelton-income-tax-california-wealthy-20190311-story.html https://www.latimes.com/politics/la-pol-sac-skelton-income-t... Note: this article is from 2019, which is obviously pre-Covid. I still think it’s too early to predict any trend on post-Covid migrations (which would really be captured and 2022-2023 and 2023-2024, assuming you started planning to leave mid-pandemic 2021-2022) California had its largest tax surplus in the history of a state ever the 2022 fiscal year.
- Modified3019 3y ago
  FYI, unless they fix their tax system, they are currently headed towards a (last I checked) 30+ billion dollar deficit this year. They also recently raised taxes on income over (I think) $1 million again last year, and I believe plan to continue to do so. Also for a more up to date perspective on migration and money: https://calmatters.org/commentary/2022/08/california-is-leaking-vital-high-income-taxpayers/ https://calmatters.org/commentary/2022/08/california-is-leak... https://www.sfchronicle.com/sf/article/San-Francisco-migration-17353393.php https://www.sfchronicle.com/sf/article/San-Francisco-migrati... Regardless, this still supports my point that state level healthcare while far more durable than local gov, still can’t compare to national level stability.

Amezarak 3y ago

Hospitals and public health systems owned and operated by city and county governments are not actually unusual in the US. They're fairly common.

dangus 3y ago

There really isn’t anything that constitutionally prevents the federal government from establishing universal healthcare. See Medicare and Medicaid.

lokar 3y ago

In the large, the issue is taxes are too low to support current spending. Only the federal government can run a sustained deficit. Republicans aggressively take advantage of this to cut taxes while disingenuously complaining about debt.

cabaalis 3y ago

I don't know about other states, but my state Tennessee and its counties do just this. I'd be willing to bet it's more common than not across the US. https://www.tn.gov/health/health-program-areas/localdepartments.html https://www.tn.gov/health/health-program-areas/localdepartme...

mbgerring 3y ago

San Francisco started doing something like this in 2007: https://en.m.wikipedia.org/wiki/Healthy_San_Francisco https://en.m.wikipedia.org/wiki/Healthy_San_Francisco