New California Law Takes a Step Toward Single-Payer Healthcare

Gov. Gavin Newsom signed a bill Saturday that sets the stage for California to work toward universal healthcare, such as a single-payer system that progressive activists have sought for years.

The law could help California obtain a waiver that would allocate federal Medicaid and Medicare funds to be used for what could eventually become a single-payer system that would cover every California resident and be financed entirely by state and federal funds.

California’s health secretary will have to offer recommendations on crafting the federal waiver by June 1, 2024, under Senate Bill 770.

“With this signature, California takes a historic step toward universal healthcare,”said a statement from the bill’s author, Sen. Scott Wiener (D-San Francisco). “The state will now begin answering the complex question of how we can access federal financing to fund a universal healthcare system like single-payer.”

For decades, Californians have tried and failed and tried again — just about 10 times — to overhaul the state’s healthcare system. But attempts at a sweeping overhaul have been stymied by enormous costs, legal and bureaucratic hurdles and disagreement among groups within the healthcare industry.

Wiener’s legislation represents an incremental approach that will kick-start the process of solving one piece of a complicated puzzle, rather than attempting a massive revamp of the healthcare system.

Supporters of a single-payer model find fault with the existing healthcare system that leaves many patients paying astronomical co-pays and some haunted by fear of the debt they will accrue from medical procedures.

While the bill had support from many healthcare reform advocates, it faced opposition from both ends of the political spectrum. Critics on the left said it doesn’t go far enough in moving California toward single-payer healthcare, while critics on the right said it represents an ultimate goal of abolishing private health insurance and increasing taxes.

The California Nurses Assn., which has advocated for single-payer healthcare for decades, opposed the measure, contending that the work the bill asks the California Health and Human Services Agency to do has already been done.

Carmen Comsti, a lead regulatory policy specialist for the nurses union, said the bill would be an “unnecessary” waste of state resources.

Michael Lighty, president of Healthy California Now, the sponsor of Wiener’s bill, countered that the legislation promises a universal system, which could include a single-payer system.

“What we made clear is there is no preordained outcome,” Lighty said.

Cindy Young, a board member of the California Alliance for Retired Americans who supports Wiener’s bill, stressed that time is of the essence, particularly for California’s aging population.

“There are things seniors can’t get or it’s eating up our pension money to be able to pay for those things,” said Young, 68. “Long-term care is an absolute necessity. What’s going to happen to us if we can’t take care of ourselves?”

Click here to read the full article in the LA Times

California’s Single-Payer Health Care Plan Would Be Costly and Risky

MedizinSingle-payer health care is e a major issue in California’s 2018 gubernatorial election. Democratic candidate Gavin Newsom has strongly endorsed the idea, while Republican candidate John Cox is opposed. Last year, a single-payer bill, SB 562: The Healthy California Act, passed the state Senate but was placed on hold in the Assembly.

SB 562 would replace the current health care system with a state program under which all provider claims are paid centrally with no network restrictions, deductibles, co-pays, or other limitations. One governing body would replace the current array of public and private insurers. Medicare, Medi-Cal, and the Children’s Health Insurance Program (CHIP) would be integrated into the new system.

Proponents of single-payer primarily tout its ability to move the state towards universal coverage. However, California is already fairly close to achieving universal coverage. The June 2017 CDC report states that only 6.8 percent of Californians are uninsured. The other 93.2 percent already have private insurance, Medi-Cal, or gained insurance through Covered California during the Affordable Care Act (ACA) expansion.

Creating a single-payer health care system would be enormously costly, time-consuming, and difficult from a political and implementation standpoint. If achieving universal coverage is the primary goal, existing insurance schemes and government programs could be expanded to cover the uninsured instead. If Medi-Cal coverage is considered insufficient, it could be enhanced without impacting other categories of insurance.

A major argument from proponents of single-payer is the claim that it saves money by eliminating profits and administrative overhead — money that is going to insurance providers. Relative to all health care costs, these amounts are quite small. Most California residents already have coverage either through the government (Medi-Cal or Medicare) or a non-profit provider (Kaiser Permanente or Blue Shield), so profits only enter into the equation for a minority of Californians. Second, SB 562 would remove incentives to control costs, eliminating managed care. As a result, provider charges would probably increase substantially, overwhelming any savings from the elimination of middlemen.

Kaiser Permanente, the nation’s largest non-profit health plan and the insurer for many Californians, is known for its high quality of care and cost-conscious decision-making. A single-payer system would eliminate managed care organizations, and with them, the years of efficiency gains made to eliminate wasteful spending and improve quality. A statement by Kaiser’s CEO last year emphasized the difference between universal coverage and single-payer, mentioning his hesitations with single payer’s outdated fee-for-service model.

Perhaps the most daunting challenge of a single-payer system is the price tag. Analyses estimate that implementing a single-payer system would cost California between $330 billion and $400 billion per year, and there are reasons to believe that these estimates are too low. To put the potential costs in perspective, the entire California state budget for 2018-2019 is $201.4 billion. SB 562 does not provide details about how funds would be raised to pay for single-payer.

Furthermore, SB 562 has no mention of cost control measures, while explicitly saying there will be no co-pays, deductibles, or premiums. It plans to cover all medically necessary care, including medical, vision, dental, hearing, and reproductive services. Other services like chiropractic care and acupuncture would also be fully covered under the new program.

Many other countries have universal health care coverage and better health outcomes than the United States, an argument frequently used in favor of single-payer. However, many of these countries utilize free-market mechanisms that promote cost-conscious decision-making. These include price transparency, fewer regulations, consumer choice, and cost-sharing to prevent overuse of services.

Aside from the fundamental problems aforementioned, there are considerable political and legal roadblocks associated with implementing a single-payer system in California. Assuming that tax increases would be a necessity for funding purposes, a key obstacle would be gaining the two-thirds vote requirement for passing any such increases in the state legislature. Other obstacles include Proposition 4 of 1979, referred to as the Gann Limit, which limits state and local appropriations. Implementation of a taxpayer-funded single-payer system would necessitate repealing the Gann Limit or exempting the new taxes from the limit. Proposition 98, passed in 1988, requires that a certain amount of state tax revenues be diverted toward education funding and taxes for a single-payer system would fall into this category. So, once again, voters would have to approve exempting these new taxes from Prop. 98.

Proponents of the single-payer system believe that the new taxes needed to fund it could be addressed in legislation without requiring voter approval. The California Budget & Policy Center sees this as “very unlikely,” since it would require amending the state Constitution. When it comes to Proposition 98, the likelihood of exempting new taxes is less clear, since it depends on differences between the General Fund and Special Fund, potentially opening the door to a lawsuit.

Much uncertainty exists about the possibility of rolling federal funding into the California Health Fund (a new fund from which the state government would pay all medical expenses). The federal government funds Medicare and most of Medi-Cal, setting or at least influencing eligibility rules. This creates a hurdle to covering undocumented immigrants; federal funds are currently not allowed to finance any of the social services provided to this population.

The combination of the political and legal complications, SB 562’s enormous price tag, and the lack of cost-control measures and long-term funding uncertainties need to be carefully considered by Californians. Vermont tried to implement a single-payer health care system in 2014 but ultimately abandoned it following a myriad of challenges. Vermont had a population of 625,000 residents at the time. California’s is home to nearly 40 million people. Increasing access to health care is a laudable goal, but changes to the system should focus on improving health care outcomes for patients and  improving the quality and affordability of care. Increasing the state government’s role in health care is unlikely to deliver those results.

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The Missing Item in Health Care Discussion — the Tax Code

MedizinAttempts at creating a single payer health care system have stalled so a group of liberal organizations are backing a package of bills to achieve a form of universal coverage. But you can pull out the same label on this attempt that sidetracked single payer—“woefully incomplete.”  They don’t want to say how much this universal health care plan will cost or where the money is coming from.

Sure the state treasury is brimming with unexpected cash and the budget is at an all time high. However, anyone who has ridden the California budget rollercoaster over the last couple of decades knows that flush times won’t last.

Creating new entitlements on health care that provide subsidies as called for in the plan and includes all residents despite legal status has big dollar signs all over it.

The single payer proposal was weighted down with a $400 billion price tag. Even if the new effort would cost a smaller portion of that amount, the health care change would still add billions to state spending.

Tax increases would probably be part of the proposal to cover the cost. It is hard to see how they can be avoided. But, the M.O. of those seeking tax increases generally has been to get support for tax measures by limiting tax increases on someone else — the rich or corporations are favorite targets.

Such an idea just adds another story onto a tax structure built on a wobbly foundation. When the next economic downturn hits, the structure crumbles and many government programs will be gasping for fiscal oxygen, especially the proposed universal health care.

If health care reformers want to create a new way to expand health care coverage, they first better consider thinking about a tax code that will not undercut the economy and at the same time be able to better manage economic pitfalls.

Such a bill doesn’t exist in the proposed healthcare reform package.

ditor and Co-Publisher of Fox and Hounds Daily.

This article was originally published by Fox and Hounds Daily

California single-payer health bill shelved – for now

Pills health careSACRAMENTO – Assembly Speaker Anthony Rendon, D-Paramount, an avowed supporter of single-payer health care, nevertheless announced last week that he was pulling the plug on a Senate-passed measure that would create such a system in California.

Rendon, who is holding the bill in committee, was only the proximate cause of AB562’s death. Its fate was sealed after a Senate floor analysis last month pinned its likely cost at $400 billion – more than three times the state’s entire general-fund budget.

“It didn’t make any sense,” Rendon recently told the Sacramento Bee. “It just didn’t seem like public policy as much as it seemed a statement of principles. I hope the Senate takes this chance to take the bill more seriously than they did before.”

According to its bill language, the Healthy California Act would “provide comprehensive universal single-payer health care coverage and a health care cost control system for the benefit of all residents of the state.” The measure would have tossed out California’s myriad systems of private, insurance-backed and government-funded health care and replaced it with a single, government-managed system run by a newly created state agency.

Such a massive change would demand volumes of detailed legislative language, yet the bill itself was remarkably brief and lacking in specifics. It even failed to include any explanation for how it would receive the necessary waivers from the federal government.

The Appropriations Committee analysis concluded the bill would lead to “increased utilization of health care services,” given that all residents would be free to “see any willing provider, to receive any service deemed medically appropriate by a licensed provider, and the lack of cost sharing, in combination, would make it difficult for the program to make use of utilization management tools such as drug formularies, prior authorization requirements, or other utilization management tools.” So all financial bets were off, given an expected – and probably massive – hike in demand.

To fund the $400 billion program, the Appropriations Committee concluded the state would have to raise about $200 billion in new tax revenues. That would mean a new 15 percent payroll tax, with no cap on the wages subject to the tax. Shifting any of those costs from taxpayers to enrollees would be impossible under provisions that prohibit “members from Healthy California from being required to pay any premium” or “from being required to pay any co-payment, co-insurance, deductible and any other form of cost-sharing for all covered benefits.”

State officials often argue about programs that spend millions of dollars, but had a surprisingly short debate about one that would cost hundreds of billions of dollars. One reason that might be is that Gov. Jerry Brown already had expressed deep skepticism about the measure. “This is called ‘the unknown by means of the more unknown,’” he told reporters in March. It was unlikely he would have signed it, especially given his concern about creating new spending programs. Critics argue that the governor’s public views gave Democrats a free pass to vote for it and assuage their political base while knowing it was unlikely to become law. Rendon’s comments to the Bee certainly give ammunition to those who saw the bill as a half-baked “statement” bill.

Support and opposition fell along predictable and partisan lines. Liberal interest groups, unions and Democratic politicians typically supported the bill, while conservative groups, taxpayer organizations and Republicans opposed it. Some groups expressed views similar to Rendon’s – supporting the single-payer concept but expressing concern about specifics.

The latter, cautious point of view won the day. After all, the bill raised more questions than it answered. It’s unclear how the new system would work or how the new government agency would operate. There are questions about the effects a 15 percent payroll tax would on the economy and jobs creation and about the magnet effect if California created an unlimited, valuable new benefit available to anyone who simply lives in the state. There are questions about federal waivers and how the California system would intersect with federal programs. And that’s just for starters.

Instead of trying to answer those questions thoroughly, the bill’s backers did as Rendon suggested – introduced a measure that stated some principles and goals, but didn’t really explain how the state government might fund them. Given the debate the health care issue sparked at the latest state Democratic Party convention and on the floor of the Legislature, it’s clear that the single-payer issue will be around or a while, regardless of the fate of this particular bill.

Steven Greenhut is Western region director for the R Street Institute. Write to him at

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Supporters of single-payer must explain how to pay for it

Healthcare costsSince the best feature of the Healthy California Act is that all health care will be free, it seems churlish to suggest that someone must pay for something.

Sadly, even after asserting more than $70 billion in new savings from efficiencies that highly motivated private providers and government regulators have not achieved, and after assuming that federal authorities will hand over about $150 billion in program funding and tax subsidies for use by state health care officials, the academics hired by program proponents find that revenues still fall short by $106 billion.

That’s in year one. Before health care inflation kicks in and utilization of free health care services metastasizes. An analysis of the measure by the author’s own staff found that, “Given all the factors that would make utilization management difficult, a 10% utilization increase is likely a conservative assumption.” That translates into tens of billions annually in higher health care costs.

So how does one resolve an annual $106 billion hole in the state’s health care budget?

  • Double the personal income tax? Nope. That will only bring in $89 billion.
  • Quadruple the state sales tax? Nope. That will only bring in $98 billion.
  • Ok, increase the corporate tax by eight-fold. Sorry, that’s just $87 billion.

But California already is a tax machine. This can’t be that hard.

Actually, it isn’t that hard, if you’re willing to dive deeply into the dumpster of discarded ideas.

Voila! That’s where you’ll find the gross receipts tax, the revenue stream preferred by academics supported by the bill’s union sponsors.

A gross receipts tax is levied against the receipts of a sale by a business of a product or a service. According to the Tax Foundation, “gross receipts taxes are largely a historical novelty to the developed world because it is a singularly unsuitable tax for the modern age.” It is economically inefficient, inequitable, and nontransparent.

The tax is not based on profits, wealth, measures of income, or any other indicator of consumption power that is the signal feature of most taxes in modern developed economies.

The tax gives a competitive advantage to bigger businesses that can make their own inputs rather than buy them. As taxes get added to the various stages of production they “pyramid” into the final price, so that the effective tax rate on goods exceeds the tax rates presented to final consumers. Businesses that must pass through this pyramided rate are less competitive than businesses that can integrate value added processes internally.

For the most part, the gross receipts tax is an artifact of history, trendy about a century ago, but abandoned by much of the world for a very long time.

A handful of states have retained versions of a gross receipts tax at very low rates, mostly far less than one percent of sales.

But even more states are abandoning this archaic tax. Indiana, New Jersey, Kentucky and Michigan all repealed their gross receipts taxes within the past 15 years. Even progressive Oregon voters swamped a gross receipts tax at the polls last year.

It takes a tax that bad to support the single-payer plan in California.

The putative rate for the California gross receipts tax would be 2.3 percent, about the same as the 2.5% tax that lost by 19 points in Oregon last year. (Only one state has a gross receipts tax anywhere near this rate, that’s on radioactive waste by Washington state.)

But wait, there’s more.

According to the academics, even a 2.3% gross receipts tax is not enough to close the funding gap for single-payer. (It “only” raises $92.4 billion.) So sponsors also suggest a new sales tax to top up revenues – not only on goods but on many services. This new tax – also at a 2.3% rate – would raise $14.3 billion, the equivalent of a 58% increase of the existing state sales tax.

Still … this may not work.

Implicitly acknowledging that their multi-layered sales tax mechanism may be a nonstarter, the academics suggest a payroll tax as a fallback revenue source to replace the gross receipts tax. While they believe a gross receipts tax is the superior mechanism because it “does not discriminate in its impact between labor-intensive and capital intensive firms,” they nonetheless calculate that a payroll tax paid by both employees and employers at a 3.3% rate would raise sufficient taxes to replace the gross receipts tax and fill the revenue need.

Existing payroll taxes for Social Security, Disability Insurance, Unemployment Insurance are capped at certain wage levels. This new payroll tax would not be capped – similar to the payroll tax for Medicare. The Medicare tax is 1.45% of payroll for both employers and employees, so this new payroll tax would be the equivalent of more than doubling the existing Medicare tax – which taxpayers would continue to pay even if Medicare spending is consolidated with the single-payer plan.

To conclude, under the most absurdly favorable circumstances – never-before achieved cost savings, minimal health care inflation and utilization increases, and enthusiastic cooperation by federal officials – a single-payer plan would require either an untried and economically unsound gross receipts tax, a new sales tax on services, or an record state-level payroll tax.

Yet somehow the single-payer bill is still considered a serious proposal.

resident of the California Foundation for Commerce and Education.

This article was originally published by Fox and Hounds Daily

Single-Payer Health Care Might Violate Key Taxpayer Protection

Healthcare costsThe California Senate voted late on June 1 to create a single-payer health-care system that will cover every resident in the state with no money out of their pockets. But this “free” health care would be anything but. Its costs are going to be steep, painful, probably deadly – and might violate a key taxpayer protection in the State Constitution known as the Gann Limit.

Under the Healthy California Act (Senate Bill 562), the state would cover all medical expenses, even those incurred by illegal immigrants. There would be no premiums to keep current, no deductibles to meet before coverage starts, nor copays to contribute. All must participate, even those happy with their employer-provided health insurance or their private individual plans.

The cost? A mere $400 billion a year, according to a Senate Appropriations Committee estimate. For those who worry about such details – which apparently excludes the 23 Democrats who voted for the bill – that’s more than three times the state’s proposed 2017-2018 $124 billion General Fund budget.

But maybe there’s nothing to worry about. A report funded by the California Nurses Association said single-payer will cost a mere $331 billion a year – only about 2.67 times the proposed state General Fund budget.

So what would we get for either $400 billion or $331 billion? Top-flight medical care that’s always available? Hardly. With more 40 million across the state – including an estimated 2.35 million illegal immigrants – placing demands on the system for “free” services, care will be rationed, wait times unbearable, and treatment and medical outcomes will suffer. Californians may have the privilege of paying a new 15 percent payroll tax to fund half the cost, if the Senate Appropriations Committee’s recommendations are adopted, with the rest coming from existing federal, state and local funds that would be redirected into the system.

Or maybe we’ll instead be mugged by a 2.3 percentage point increase in the state sales tax, along with a 2.3 percent gross receipts tax for businesses. This is how the California Nurses Association study plans to raise about $106 billion, with the remainder taken from federal and state sources.

It is the massive proposed state spending increases where the single payer proposal runs into trouble, even if it passes the Assembly and is signed by Governor Brown – both unlikely propositions.

The Gann Limit is the 1979 proposition approved by voters that imposes state and local government spending limits. The Senate Appropriations Committee says that “to successfully implement the bill” and fund it with the 15 percent payroll tax, “the voters would need to amend the State Constitution to either repeal the Gann Limit or exempt the taxes to fund the Program from the Gann Limit.”

Since support for the single-payer system drops from 65 percent to 42 percent if it requires a tax hike, according to the Public Policy Institute of California’s poll, it likely would be rejected at the ballot box.

Californians may also be asked to suspend Proposition 98, which dedicates a portion of state tax revenue to fund education, to implement single-payer. Absent a voter-approved suspension, the Senate Appropriations Committee notes that half of the proposed new taxes for single-payer would go to education. Prop. 98 has become a sacred cow of state politics, and its suspension will be no easy task.

Californians are already overtaxed. Yet lawmakers are thinking about adding to the load just months after they passed a $52 billion tax hike for transportation. California has the highest marginal state income tax rate in the country at 13.3 percent and the highest state sales tax. For the fifth consecutive year, the Small Business and Entrepreneurship Council’s Small Business Tax Index ranked California dead last.

The collective crush of these tax burdens are factors in the exodus of those leaving California for better economic opportunities elsewhere. Creating an enormously expensive single-payer system will only produce more economic refugees, including the former employees of health care giant Kaiser Permanente, which has said that a single-payer system will put it out of business in California.

While the financial costs would be extreme, the human costs are likely to be worse. Pacific Research Institute President Sally Pipes recently noted that single-payer systems have allowed hundreds of veterans awaiting care in the US VA hospital system to die; caused a “humanitarian crisis” in Britain; and triggered a stream of Canadians leaving behind their “free” care to seek treatment in America.

During the national health care debate in the 1990s, P.J. O’Rourke somewhat famously said that “if you think health care is expensive now, wait until you see what it costs when it’s free.” It’s an insightful observation anyone can understand. Yet its simple logic is lost on the political majority in Sacramento that seems to determined to drive California into Blue State ruin.

Kerry Jackson is a fellow with the Center for California Reform at the Pacific Research Institute.

This piece was originally published by Fox and Hounds Daily

California’s Single-Payer Healthcare Bill Isn’t Based in Reality

As reported by National Review Online:

On Thursday, the California state Senate passed Senate Bill 562, which seeks to establish a statewide single-payer healthcare system.

Democratic senator Ricardo Lara, the chairman of the Senate Appropriations Committee, co-authored the bill and advocated its passage, but failed to explain how the proposal’s $400-billion price tag will be financed.

The bill represents a key progressive goal, and yet, it will almost certainly never be signed into law — even though Californians have elected Democratic majorities to both legislative chambers and a Democratic governor. Why not? Because it’s absurdly expensive. This year’s entire state budget is $180 billion. The single-payer system called for in 562 costs more than double that. …

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