Universal Healthcare?

[MichaelB]

Quote:

Originally Posted by haha Well if it were in America, to be more accurate something around 45% of the citizens would pay for it, their own, and the other 55% ers share too. And since taxpayers tend to be more prudent in other areas of life, including health and hygiene, the 55%ers likely would make a bigger draw per capita from the system. Great system if you are a booze-hound slacker Ha

The single largest tax benefit in the US is the tax credit for health care to employees. Over the next decade the biggest healthcare subsidy is not ACA or Medicaid. Even combined they will cost 1/3 less than the tax credit to people getting their health care from employers.

Medicare recipients also get a significant subsidy, but I haven't seen the numbers broken out anywhere.

[ShokWaveRider]

Quote:

Originally Posted by 6miths As an MD and consumer in the Canadian system - I think it's among the best in the world. As an MD in the American system (now years ago) - not so much!

But (Big But), if a new young family, unfortunately has a child with (God Forbid, and I am not religious) has a child that needs a lot of surgeries and car for a long time, does not have the rest of their financial life ruined because oif the costs of paying for their child's care.

This is a BIG one that would NEVER happen in a universal system.

[ShokWaveRider]

Quote:

Originally Posted by 6miths And bear in mind that the government doesn't pay for it. Citizens pay for it. The government just cuts out all the middle men with their fingers in the pie and is able to negotiate costs with caregivers, drug companies, hospitals, etc. One can go online in Ontario (and I am guessing most Canadian provinces) and find out exactly what a doctor is paid for a consultation, visit or procedure and with only a little bit more effort (looking up a phone number and calling the hospital) you can find out how much a stay will be with reasonable accuracy.

Massive +1

[pb4uski]

Quote:

Originally Posted by MichaelB The single largest tax benefit in the US is the tax credit for health care to employees. Over the next decade the biggest healthcare subsidy is not ACA or Medicaid. Even combined they will cost 1/3 less than the tax credit to people getting their health care from employers. ....

I think you're really talking about the fact that employer provided health insurance is deductible by the employer but not taxable to the employee. I think the employer should get a deduction for the cost of providing employee health insurance. Further, I think that employer provided health insurance should be taxable to the employee just like if the employer provided an employee with a car or a country club membership or similar personal expense and then the employee could take a deduction if they qualify. IOW, the tax implication to the insured should be the same whether the health insurance is paid for by the employer or by the insured.

[donheff]

Quote:

Originally Posted by nvestysly I strongly believe ever-increasing health care costs are due in large part because many users have little (or no) "skin in the game."

The skin-in-the-game theory may have some merit for controlling costs but it isn't the primary problem. Countries with UHC programs that involve no skin-in-the-game get better health outcomes than the US with far lower costs. I have not seen statistics comparing costs in UHC programs that include skin-in-the-game and those that don't. It would be interesting to see whether there is a strong correlation.

[ziggy29]

Quote:

Originally Posted by pb4uski I think you're really talking about the fact that employer provided health insurance is deductible by the employer but not taxable to the employee. I think the employer should get a deduction for the cost of providing employee health insurance. Further, I think that employer provided health insurance should be taxable to the employee just like if the employer provided an employee with a car or a country club membership or similar personal expense and then the employee could take a deduction if they qualify. IOW, the tax implication to the insured should be the same whether the health insurance is paid for by the employer or by the insured.

I'm not dogmatic one way or another, but the tax rules for employers paying for health care need to be the same as if individuals purchase their own. There should not be a tax advantage to employer-provided insurance that individuals don't get. Whether that means taxing both, exempting both or taxing the employee for the value of employee benefits, I'm not going to dig my heels in there. But for the sake of basic fairness the rules have to be the same. I'll let the sausage-makers work out the details.

A system that provides skewed incentives to link health care coverage to employment status are significant factor in the brokenness of the US healthcare delivery system, or at least in terms of how to pay for it and our ability to pay for it.

[pb4uski]

I agree and was suggesting that the employee rules be conformed to be the same as those for people who pay for their own health insurance, but you're right that it could be conformed to be the other way - we agree that the important thing is that they be the same. If that was done, then it would become easier to divorce health insurance from employment.

[MichaelB]

Quote:

Originally Posted by pb4uski I think you're really talking about the fact that employer provided health insurance is deductible by the employer but not taxable to the employee.

Yes. This tax credit is projected to cost around $3T over the next decade. The point raised by both you and Ziggy, that everyone should be subject to the same tax and deduction rules, makes lots of sense.

[samclem]

Quote:

Originally Posted by pb4uski If that was done, then it would become easier to divorce health insurance from employment.

Ironically, while the ACA makes it easier in one way to get away from employer-sponsored plans (because the exchanges/infrastructure is in place to accept those with formerly-provided employer plan), it penalizes employers who go that route (through the fine/taxes whatever). But I think employers will increasingly choose to dump their plans regardless of the fine, and the CBO thinks so, too

Quote:

In their original analysis of the impact of the legislation, CBO and JCT estimated that, on balance, the number of people obtaining coverage through their employer would be about 3 million lower in 2019 under the legislation than under prior law. As reflected in CBO’s latest baseline projections, the two agencies now anticipate that, because of the ACA, about 3 million to 5 million fewer people, on net, will obtain coverage through their employer each year from 2019 through 2022 than would have been the case under prior law.

[scrabbler1]

I have posted here before about the inequity in the tax treatment of HI premiums between those in employer group plans versus those in individuals plans. There are 3 different types of treatment.

(1) The tax-free portion paid by employers.

(2) The tax-deductible portion those in group plans can always deduct regardless of AGI, and it doesn't matter if the employee itemizes his deductions on Schedule A. It's like a 401k deduction, it comes right off the top of income. Individuals at best can deduct only the portion above 10% of AGI if he is even itemizing to begin with.

(3) After-tax dollars are used. Those would be the first 10% of AGI if the indivdual can itemize his deductions or the whole thing if the individual can't itemize.

Those in group plans pay for their HI premiums using (1) and (2). Individuals use at best (2) and (3) and often only (3), as was the case for me in my first few years of ER. What I propose is to have everyone in (2). To do that, the employer-paid part gets taxed as income while any remaining part of one's HI becomes fully tax-deductible the way 401k or IRA deductions are deductible; they come off the top of income and it doesn't matter if one itemizes deductions or not. This would also simplify one's taxes because fewer people would itemize once HI premiums are removed from Schedule A.

[samclem]

Quote:

Originally Posted by scrabbler1 What I propose is to have everyone in (2).

What is the justification for making HI expenses tax deductible? There's no deduction for food, shelter, etc (except as provided for by the personal exemption/standard deduction). Making HI costs deductible provides a relatively larger benefit to higher income people and to the extent it is a govt subsidy it can be expected to increase prices (more dollars chasing the same amount of goods/services).
If we assume a given national tax burden, every reduction in national taxed income results in a necessary increase in tax rates. I'd prefer fewer carveouts and lower rates, barring some good reason for doing otherwise.

[pb4uski]

Quote:

Originally Posted by samclem Ironically, while the ACA makes it easier in one way to get away from employer-sponsored plans (because the exchanges/infrastructure is in place to accept those with formerly-provided employer plan), it penalizes employers who go that route (through the fine/taxes whatever). But I think employers will increasingly choose to dump their plans regardless of the fine, and the CBO thinks so, too

I wonder if an employer would be subject to a fine/tax if they replaced their HI plan with a monetary "allowance" to the employee that would be taxable income to the employee. Even if it were expense neutral to the employer at adoption, the employer would be spared exposure to future cost increases and the treasury would get revenue in the form of more individual income taxes rather than the fine/tax on the employer and it would level the playing field between employer-provided HI and directly purchased individual HI.

It could also solve the potential issue where employers end up providing different subsidies for individual, couple and family coverage since it would be the same amount for each employee. Employers shouldn't compensate differently depending on marital/family status so HI subsidies shouldn't be different either.

[pb4uski]

Quote:

Originally Posted by samclem What is the justification for making HI expenses tax deductible? There's no deduction for food, shelter, etc (except as provided for by the personal exemption/standard deduction). Making HI costs deductible provides a relatively larger benefit to higher income people and to the extent it is a govt subsidy (more dollars chasing the same amount of service it can be expected to increase costs (more dollars chasing the same amount of goods/services). If we assume a given national tax burden, every reduction in national taxed income results in a necessary increase in tax rates. I'd prefer fewer carveouts and lower rates, barring some good reason for doing otherwise.

You could make the same argument for medical expenses, property taxes, state income taxes, mortgage interest, charitable contributions, and all other deductible expenses. There is a deduction for shelter now in the form of property taxes and mortgage interest.

If I were king I would get rid of all itemized deductions but I don't see that happening, so the idea would be to make the tax implication of health insurance the same whether it is deductible or not. IMO, it is politically more palatable to make employer-provided HI taxable to the employee and deductible by the employee to level the playing field with taxpayers who have to purchase their own HI.

[scrabbler1]

Quote:

Originally Posted by pb4uski You could make the same argument for medical expenses, property taxes, state income taxes, mortgage interest, charitable contributions, and all other deductible expenses. There is a deduction for shelter now in the form of property taxes and mortgage interest. If I were king I would get rid of all itemized deductions but I don't see that happening, so the idea would be to make the tax implication of health insurance the same whether it is deductible or not. IMO, it is politically more palatable to make employer-provided HI taxable to the employee and deductible by the employee to level the playing field with taxpayers who have to purchase their own HI.

+1 although I'd only get rid of some deductions and cap others.

My proposal to move everyone into the middle type [(2)] would very likely increase tax revenue because there is more income to be taxed in (1) moving to (2) than income taxes lost by moving (3) to (2).

I'd actually prefer fewer carveouts with rates not being lowered because we have had too many carveouts and credits and tax cuts which never had any base-broadening offset but that's a subject for another thread, perhaps.

[imoldernu]

As the US spends twice as much on healthcare as our Canadian neighbors, the question naturally arises not just "Why", but also "Where". Not just how much, but where does the extra money go?

This article, while rather intense in detail, offers some insight into the costs... not just the cost to the taxpayer, but the differential in Prices, Procedures, and Administrative Expenses. With the roughly "par" value of the US and Candian dollar, it points up the effect of legislation and regulations.
Medical Spending Differences in the United States and Canada: The Role of Prices, Procedures, and Administrative Expenses

But that is just part one... Part two would be Pharma regulations, and Part three might be the approval of standards for medical fixtures and equipment required for government reimbursement.

One example of Part 3 might be that medicare, on approval, may ok full or partial cost of products such as hospital type beds, walkers, or wheelchairs. Besides requiring Doctor approval, the items must be approved by medicare... manufactured according specification. While this may be good for the patient, the standards may set costs that could be non competitive. Ie. an item that receives approval, using standards that are only met by a single supplier. Yes, there are competitive bidding opportunities, but decisions may be suspect... allowing approval on standards that set a higher cost bar or retooling by manufacturers.
Durable medical equipment (DME) coverage | Medicare.gov

[Bryan Barnfellow]

Quote:

Originally Posted by pb4uski That sounds like a sensible system to me other than the restriction to be treated in your own canton. Is there some provision for people who travel or do you need to buy a supplemental policy if you travel?

Switzerland is a federation of 26 strong cantons. The federal government has very little power (federal taxes are dwarfed by cantonal and municipal taxes, and the federal government keeps our 3 fighter jets in the air ;-)

Thus, the restriction to within your canton's borders. I believe that the Swiss insurers will pay for emergency treatment costs in other countries; but not normal run-of-the-mill health services.

I forgot one other benefit -- the Swiss insurers will pay a significant portion of your gym costs. They recognize that it will save money in the long run.

BB

[nuke_diver]

This is an interesting discussion...though I imagine it will never really happen here. IMO there still is too much of the "for profit" mentality when it comes to HC. As a Canadian living in the US I've gotten to see both sides. As I (rapidly) approach retirement the CDN system has a lot of appeal to me. If I move to BC my HC cost will be in the 1-3K a year depending on what I get and what I need (ie buying travel ins etc). In the US it will be in the 15K range for my wife and myself depending on what ACA policy we get and what we actually need (early on with both healthy not much but an accident could change that in a hurry). In terms of budgeting it is much easier to budget for HC in the CDN system as I don't need to budget for such a large reserve....just in case. I could live on a lot less there than here.


But the weather won't be near so nice....I mean it hasn't snowed in 24yrs that I've been here ...least not at sea level

[nvestysly]

Quote:

Originally Posted by Bryan Barnfellow I have lived in Switzerland for about 5 years now and like the Swiss model. It is "universal" in the sense that it is compulsory for everyone in the country who is here for more than 3 months. However it is not a single payer plan and is not connected to employment, which makes it portable. Individuals pay for it and do so all of their lives. If you cannot pay the whole premium, your canton (=state) will assist you based on your income. But you own the policy/contract. There are no pre-existing conditions exclusions and your premiums cannot go up due to your own medical experience -- they are tied to your age group. My premiums have gone up 1 or 2% each year at most. One year they did not go up at all. It was a shock. For the basic insurance plan, which is compulsory, the government (or a governament commission, not sure) determines what illnesses are covered and publishes a drug formulary; but it is very comprehensive. It's like the US Blue Cross/Blue Shield used to be. There is no hassle with getting health services (you can go to a general practitioner or directly to a specialist). You show your insurance card and they bill the insurer. The basic plan is reasonably priced and includes medications and even spa treatments if these are prescribed by a doctor for physical ailments or stress/burnout. Also if you are physically unable to care for yourself or your home due to an illness, you can receive home help until you are better. Some alternative medicines are covered as is acupuncture, for example. So you get doctor visits, lab stuff, medications/equipment, and hospitalization. What you do not get is a private room in a hospital (only semi-private) or the ability to go outside your canton for treatment. If you want that, you buy a supplemental policy, which about 20-30% of Swiss residents do. It allows for some other benefits as well. Most people are okay with the basic plan. You can never be dumped by your insurer and you can change once a year to another if you would like. The medical staff are well trained and often speak very good English. My wife had a small procedure at our local hospital and was kept in hospital for most of a week (!) to be sure she was okay, and then we had help with house stuff for two weeks following. There are about 60 nonprofit companies which offer insurance plans, competing on some aspects of price and service. So in summary, I like that it is not connected to my j*b, making it portable. It is compulsory, so the healthy youngsters are in the pool as well. It covers things like medications and is generally form-free and has the bonus of no hassles/gamesmanship. The companies pay the bills and we are almost never on the 'phone with them as we constantly were when we lived in the US. One small worry. Switzerland is a true direct democracy. This means citizens can change laws based on majority vote. There is a nationwide referendum this month to switch out the current system with a single-payer government system supported by taxes. I cannot believe this will be better for us; but I don't have a vote here. BB

Quote:

Originally Posted by Bryan Barnfellow Switzerland is a federation of 26 strong cantons. The federal government has very little power (federal taxes are dwarfed by cantonal and municipal taxes, and the federal government keeps our 3 fighter jets in the air ;-) Thus, the restriction to within your canton's borders. I believe that the Swiss insurers will pay for emergency treatment costs in other countries; but not normal run-of-the-mill health services. I forgot one other benefit -- the Swiss insurers will pay a significant portion of your gym costs. They recognize that it will save money in the long run. BB

Thanks for taking time to elaborate on the Swiss healthcare system. Your comments give me reason to believe what I thought was true - I like the Swiss approach and believe it could be adapted to the United States and be quite successful.

As others have mentioned in this thread, there are so many convoluted reasons the U.S. healthcare system is in it's current state. We've given so many tax incentives to corporations and individuals that nobody wants to change. Everyone is at the trough and likes the food they receive (to some degree). Now we've interjected direct subsidies to individuals and it's going to be hard to get that horse back in the barn.

We really need to start over and the Swiss system appears to be a good starting point. So back to the OP... my answer remains NO if we are discussing variations on what people currently think of as Universal Health Care and my answer would be YES if we are discussing an approach that is significantly different compared to how we administer health care / insurance today. Remove the employer association, make it truly portable - individuals obtain the coverage they want, allow for a voucher/subsidy depending on income (and means), provide for transparent pricing policies and make the individual more aware of how and where the money is spent and that there is not an infinite supply of money to address your every ailment.

My earlier comment on the need for a limit (or cap) was not intended to say an individual would not receive treatment but to say there are a variety of ways to treat ailments and some cost less than others. Yes, it is currently very difficult to obtain pricing. I've even been told "why do you care, insurance is paying for it!" when I inquired about the charges for a colonoscopy. Slowly, providers are changing their methods - I recently asked about prices for treatment of tennis elbow and within 5 minutes I was given itemized pricing for the arm brace, physical therapy and a steroid injection. That allowed me to determine which approach (or all three) I wanted to pursue.

[pb4uski]

Quote:

Originally Posted by nuke_diver ....If I move to BC my HC cost will be in the 1-3K a year depending on what I get and what I need (ie buying travel ins etc). In the US it will be in the 15K range for my wife and myself depending on what ACA policy we get and what we actually need (early on with both healthy not much but an accident could change that in a hurry). In terms of budgeting it is much easier to budget for HC in the CDN system as I don't need to budget for such a large reserve....just in case. I could live on a lot less there than here. ....

What will your taxes be in BC vs here? Federal, state/provincial, sales/VAT, etc.

This link suggests Vancouver is 14% more costly than LA but it doesn't address income taxes that I can tell. I assume that sales tax/VAT are covered in the items listed.

http://www.numbeo.com/cost-of-living...0&currency=USD

[nuke_diver]

using that link...which isn't going to be quite right because I would not live in Vancouver...all big cities are expensive I get and I wouldn't rent in either

You would need around 5,564.72C$ (5,038.23$) in Vancouver to maintain the same standard of life that you can have with 5,300.00$ in San Jose, CA (assuming you rent in both cities).

So $200 more a month...I'm not sure if that counts HC. Here HC is about 20% of my expected retirement total budget. Taxes are another 20 or so and the rest is living expenses. I checked into taxes and while it's a bit hard to tell because there is the possibility of double taxes tax rates in BC while not working (passive income) seem to be similar or less than US taxes. I have a friend who's a CFO in Maryland who told me similar information a while ago. While working the US is clearly cheaper, when not working the delta is less dramatic.

In order to do that move there would need to be a lot more research. The wife thinks it better to move to WA which would certainly be cheaper than either place.

My biggest expense to move to either place will be the loss of my killer gym membership deal which is $97/yr for life at 24hr fitness. None of those in any place we are considering moving.