If we’re lucky, we in California will eventually have a single-payer health system. Our legislature passed such a single payer system in 2006 and 2008, but Governor Schwartzenegger vetoed it. Right now 60% of all Americans favor such a system, so you can bet that Californians are at least 70% in favor (I did research and could find no poll figures for the state at this time).
At the moment, there is no specific plan on how to pay for the system. The most obvious way would be to tax individuals an estimated amount that they would have to pay themselves under an affordable system of uninsured health care. That would probably be based on income and just be added to the income tax system. Of course, such amounts might not be sufficient to pay all the costs, so the shortfall could be taken care of with additions to business taxes. The Republicans in Washington appear to be planning tax cuts for the wealthy as they save money on healthcare. California should simply tax its wealthiest citizens the same amount that the Federal government cuts from their tax bill.
If the California system were medically efficient, even wealthy Californians would use the local services and would go elsewhere only if the local service were deficient.
One of the issues that is not discussed is whether individuals would be permitted to evade the system by paying doctors and hospitals directly. Of course, wealthy Californians could always go to another state for their health care, but they would still be paying their taxes in California and thus contributing to pay for the system. If the California system were medically efficient, even wealthy Californians would use the local services and would go elsewhere only if the local service were deficient.
Should California doctors and hospitals be permitted to accept payment outside the single-payer system? Probably not. The only exception should be for treatment for non-Californians who need emergency care while in the state. Those persons would pay for services to the single-payer system and the latter would compensate the doctors and hospitals according to the state system. But doctors and hospital licensed by the state should be limited to provide services only within the state system. This would be like the educational system in Finland, where there are few privately owned school, and even they are not permitted to charge tuition, so effectively all students are in the same public system.
If California doctors and hospitals can only work within the one system, then there is less likely to be a “two tier” system. Presently, there is a two tier system because wealthy Californians can pay for special services within the state. The state cannot prevent its wealthy citizens from traveling elsewhere to buy services, but such travel is not likely to be important so long as the state pays for all services and provides it at a normal level. Indeed, the state could tax its citizens with a special tax for buying health services outside the state. The goal would be to encourage all Californians to use and pay for California health care. If all Californians are in the same healthcare system, we will all support (and help pay for) improvements to that system.
With the Trump administration on the attack against Obamacare, the move to a single-payer system in California is really the only way to protect and improve upon what we thought we were getting through Obamacare. Fortunately for Californians, the state is as wealthy as many countries with single-payer systems and can afford the cost. It is the sixth biggest economy in the world, right between the United Kingdom and France. Why shouldn’t it have a healthcare system as citizen-friendly as those two countries?