Alphabet is spending billions to become a force in health care
economist.com
economist.com
And there’s even more giants:
https://www.theverge.com/2022/6/10/23162503/oracle-cerner-he...
https://www.fiercehealthcare.com/health-tech/oracle-cerner-p...
Link is here if you want
https://www.nhs.uk/using-the-nhs/about-the-nhs/sharing-your-...
A few points:
I'm not against data mining at all, just handing it out to agencies without my say so. I'd be happy for it to be used for this purpose entirely within the NHS but that's not what was assured.
I don't like the approach that you have to opt out, not opt in.
I others may have different tradeoffs, that's fine. This is my view and urge people not to follow what I've done but to decide for themselves. It's your data, if you're in the UK, you can make a choice (not making a choice IS making a choice: for it to be shared).
Edit: and please don't respond with "just you wait..." or "it's going to happen anyway" defeatist juvenile posts.
Sarcasm aside I can't think of a company I'd trust less than Alphabet (maybe Meta) with managing healthcare.
You mean like, "Don't be evil"?
/s
And that's why they censored the web via the Project "Project Dragonfly"? [1]
Never forget that you are a product for Google, and Google likes to kill it's products.
[0] https://theintercept.com/2018/05/31/google-leaked-emails-dro...
We are already in a dystopian time.
Voila, behold a viola! One fourth of a string quartet!
But if you're irked by "viola", it could be worse, they could have written "wallah", which is all too frequent.
Or a flower.
Are you mixing French and Italian articles?
As an addendum wiktionary[0] is always useful when searching other meanings of a word
I haven't learned French since high school, but here's how I would translate the examples:
il la viola "He raped her"
il viola la loi "He broke the law"
Price controls and disconnecting it from employment.
A proper MRI is expensive, the analysis is slow and need experts etc.
There are plenty of things to optimize.
And when we are done with us, it has to reach the next level to become so cheap and easy to use that everyone on our planet has access to it.
> A proper MRI is expensive, the analysis is slow and need experts etc.
I'm sure that's very true. A company that's struggles to keep a rudimentary chat app running for any length of time, spectacularly miscalculated its fiber project, to name a few obvious ones, does not instill any confidence that they would be the one to improve this. The medical industry is far more conservative and far more complicated than what Google has proven it is able to deal with IMO. You can't just move fast and break things, you can make shit up as you go along, you can't invent your own standards.
> There are plenty of things to optimize.
They've also not performed impressively on any kind of "AI" related thing, if that's what they're thinking. Their self-driving cars are still a curiosity and a long way off being revenue positive, if there is even a path to it, for example. Industry and legislative inertia and baggage aside, I don't even think a big old cumbersome dinosaur like Google has the chops to come in and make a big change. Put it this way if some revolutionary new startup company had a really great idea in healthcare, you would be disappointed if Google bought them.
Google maps was and still is free, available and changed lives.
GCP is extremely innovative. From full end to end encryption including encryption on rest.
Google workspace works like a charm.
They have well working ML in all newer pixel phones for images etc.
They have tons of bleeding edge research papers on so many different ml topics (are you aware of their research blog?)
Google has one of the best / if not the best certified cloud env in the world. They already work with the biggest health service provider in the USA.
Yes.
I've seen this many times but it makes a meaningless healthcare = health correlation .
America has lots of systemic problems that affect health outcomes that are outside of healthcare. Low quality fast food, food addiction, industrialized farming, corn subsides, food deserts, deceptive food marketing to name a few.
It doesn't, it's just making an observation.
> America has lots of systemic problems that affect health outcomes that are outside of healthcare. Low quality fast food, food addiction, industrialized farming, corn subsides, food deserts, deceptive food marketing to name a few.
Sure, America has many issues and many more than you've listed. So do other countries. And they all have many differences in healthcare systems. All this makes it impossible to formulate a mathematical proof. Which fortunately I was not trying to do.
So we can't really measure the precise effectiveness of healthcare systems and health expenditure, sure. But surely the burden is on the people who would to claim that 2x healthcare expenditure for worse (or not significantly better) health than many other countries is a reasonable cost efficiency, to come up with some pretty strong evidence to support them.
yes we have healthcare system that treats disease, after that fact. Americans are a sickly group of people. Lionshare of expenditure goes to treating chronic metabolic illness. These people cannot be returned back health once they have metabolic syndromes. So matter how much money you spend on healthcare there is no real way to convert sickly ppl back into healthy people. No doctor has a way to fix diabetes or thyroid dysfunction.
Again, goes back to my original comment. "healthcare" has nothing to with "health".
>the standard of care in America is probably second to none if you can pay for it
How sure are we that these two things are unrelated?
Because I do and you know how scattered the field of medicine is?
There is one realistic way of getting more people with chronic issues new threatments and it's data. Lots and lots of it.
IF someone can pull that of while protecting the individuals I believe it's alphabet. Together with deep mind and all the other research they do.
What makes you think they will protect the "individuals"? From a privacy persepctive, I would say they have no clear incentive in doing that, given individuals are the product they sell to companies that need to push ads into society.
They know how they make their money and don't hide it. But they make you as an individual disappear.
It's a much better compromise than from any other company and they drive this topic for years.
At the end of the day, it's just you by a different name. Instead of owning it and claiming "we have this information on Gehlitio" they say things like "We have these generalizations about anybody who happens to use HN, speaks in English, bought X Y and Z, subscribes to A, <insert 100 more details that effectively fingerprint you>"
The right to be forgotten would have to be built into it all right from the get go, wouldn't it? Neural nets embed things, like you said. If Facebook pivoted towards being a hub for healthcare data as oracle seems want to do, could they use all of their facial recognition tech trained from profile pictures now that it is supposed to be detached from any one identity? I'm thinking of the equivalent of github's co-pilot spitting out comments alongside the code.
yes exactly. I am having trouble articulating my underlying point but this is along the lines of it.
A facial recognition algorithm is ultimately saying "you look similar to this specific set of people". If the training set was 1 person, for example, then the algorithm would pretty much just be saying "you look like this photo of this 1 person". Scaling that up does not improve privacy - it only blends you into a population. Additionally, it is distilling out the things about you that separate you from that population (things that make you, you) since those distinguishing features are exactly what the model needs to use as the line to draw on whether or not new data points are similar to the population set or not.
Because privacy doesn't seem all that important once you actually are going through it.
If you had to pick between being a cripple (say, with your arms or your legs useless) and forgoing your privacy are you really sure you'd give more value to privacy?
Do actually consider what life is like under these circumstances before answering. I don't think there are many quadriplegic people out there who'd pick privacy over being healed.
"X is more important than Y" isn't honest if you never lacked Y and can't even consider a future where you lack Y
My beliefs are quite the opposite of what you implied about me. I think we should move away from all this embedded bullshit and keep peoples identities intact because the generalizations will never be perfect and it might be useful to know who the actual people are that those generalizations are based on. Maybe that would facilitate human connections. Maybe that would make it easier to reward individuals for sacrificing their privacy in order to improve healthcare. Instead of just pretending they arent sacrificing privacy and are just a drop in the ocean of data providing results.
You are not a drop in the data ocean. Your data is important. There are not a lot of people like you. Google emphasizes generalization because it cheapens the value of your individual data point. Their policy creates an illusion I aim to dismantle.
Also, I do have chronic illness but that is not relevant here. Mine does not directly cause pain, though, full disclosure
Health is very personal. Family history is usually pretty relevant. I am not sure what we gain by pretending we arent talking about actual people, or that by removing your name from all your specific health details it somehow means you cant still be personally targeted. I know Google gains the benefits of less regulations, though.
I disagree on this sentiment, I don't care if there is an dehumanizing number for me in a ad context. I would prefer it over a personal id.
Anyway I still care much more for having a cure for my chronic pain.
Good for you if you don't need this.
I just disagree with the position that Google can do so while preserving privacy. If we are going to trade privacy for cures, let's at least do so openly.
I do, but I can think of no more obvious examples of a Faustian pact than having Alphabet get involved in this field.
So I guess it boils down to a difference of opinion is all.
If you give your medical information to someone/something that is not a covered entity or business associate they do not have to follow HIPAA rules.
More information here [1].
[1] https://www.hhs.gov/hipaa/for-professionals/covered-entities...
A merger of technology privacy invading, ai-guiding, rip off processes AND the ability to direct your health for profit. With government lobbyists in both pockets.
What could go right?!?
After wasting many millions on failures like Calico, Google hasn't learned that healthcare is a service that's continuous, custom, and complex. And since the "customer's" health and life are at stake, maintaining health is a damned sight more important and difficult to do sufficiently well than Google's current business: spam.
Tech companies like Google simply don't have the DNA or the persistence to succeed in science-based markets driven by R&D and heavy regulation. They want faster profits driven by higher multipliers and lower standards for accuracy than you can get in healthcare, where accuracy really counts and every case is a little bit different. In medicine it really matters if you get the right answer for your A/B test, otherwise someone may die or they may sue you. That's why so little of healthcare has been automated, and why that's likely to continue.
This is a problem for dataminers like me within pharmas too. Most of our clinical trial data is locked up contractually within contract research organizations (CROs) who are responsible for taking specific measurements of it as part of a trial. From what I've seen, dataminers within the company can gain access to only selective bits of that data (one or two features, perhaps) from all the patients in a trial, but never to all the data on each patient, and never data from the trial that spans multiple CROs.
This 'federation' of clinical trial data collection serves the needs of the trial design (and satisfies HIPPA regs), but it makes mining the data or asking new questions of it almost impossible. Too little data is available (and never longitudinal longer-term outcomes, since trial durations are short) to allow mining of more than short-term signals, like immediate response to treatment. Pharmas are unlikely to change that practice, in part because it's easier to federate the analyses and allow the raw data to remain in distributed silos. But federation is also a good way to discourage asking creative yet inessential questions that might later prove awkward or invite lawsuits, since litigation is an omnipresent worry in US healthcare.
How companies like Calico/Google hope to navigate such minefields is a question they have yet to answer successfully.
(note: I worked at google over a decade and work for pharma now. I helped establish Google's move into health care and even launched products intended for pharma users and set up the ethical guidelines to work with private data like clinical records. Unfortunately, Google's Research leadership chose to take their health efforts in a completely different direction so now I focus on stuff that will actually make a difference for pharma).
Never, or literally tomorrow if they take over. "Personalised medicine" decisions made with "AI" will provide a perfectly unaccountable black box to blame when (if ever) the general public realises that vulnerable and poor people have been getting the B end of the A/B testing.
I agree with the rest of the post but god have mercy on us if these companies take over healthcare. I never thought I'd be living in such a totalitarian state in my life.
AFAIK, crickets.
... at least it isn't facebook. Oh, sorry """Meta"""
It's so easy to blame voters but the reality is that politics is about messaging, and how is the electorate supposed be savvy enough when these companies can spend unlimited amounts of money to keep us fighting each other about this stuff? Make no mistake, Google benefits from this depravity too.
I don't have a good answer to this question, I'm wondering if others do.
No, I don't have an answer either. I just know that counter-propaganda isn't it.
Maybe things were different under the Fairness Doctrine? I don't know.
We already have free health for the poor: https://en.wikipedia.org/wiki/Medicaid
> Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States, providing free health insurance to 74 million low-income and disabled people (23% of Americans) as of 2017, as well as paying for half of all U.S. births in 2019.
What we should be doing is to fight the regulatory and bigpharma capture of US health system along with the horrible hospital + insurance racket. Google is now going to take advantage of the moat built by Big Gov and never ever allow anyone to compete.
No, we have free health insurance for some of the poor (states that have no accepted the ACA expansion have basically no coverage for adults without dependents.)
Medicaid is not (as a generality) free health care (it can be, in some states, for some recipients). It is free health insurance, which can have copayments, coinsurance, deductibles, etc.
I think if someone can afford better, private care they should be able to. For example I would probably go to the universal healthcare family doctor but if I need a specific surgery I would like to be able to go to the best care I can get.
There are tens of millions of people who have no access to Medicaid because states chose not to expand it under the ACA, and there are plenty of poor people who make more than ~$16k a year, which is the cut-off for Medicaid.
How could it be even more expensive than our current inefficient, half-baked, worst of both worlds system, which is more expensive than socialized systems in other nations? And more expensive per capita, not simply overall.
* The US spends more public money on health care, per capita, than other wealthy nations, while also spending much much more private money than other wealthy nations
* By many measures, the US gets worse outcomes (e.g. life expectancy)
The conclusion that many draw from this is that perhaps a single-payer health care system in the US could dramatically lower private spending, also lower public spending, and perhaps improve outcomes. I don't personally know if that follows, but it's not implausible.
This is counter-intuitive to many, thus comments like your (A) through (C) are common, but might not be correct.
That said, I'm not aware of evidence that your (B) is wrong. That might be part of the trade-off.
As a non-American from America's hat, who has had a few (bigco-insurance-funded) run-ins with US Healthcare, my observations were that
* emergency health care at the no-expenses-spared level in the US was nicer than emergency healthcare up here, and I wouldn't want to pit my doctors vs those US doctors in a quality competition
* US doctors seemed really eager to waste money, like really eager, like it was creepy
Your last point is purely a function of the liability culture in the states. US physicians are quite aware of what's appropriate and what's inappropriate testing wise. However, as long as a physician can be held personally liable for any oversight - meaning that the results of an entire career can be lost - they're going to over-test.
I'll note that I do have a few different bits of modest evidence to the contrary. But I wanted to focus my comment on concrete observations (both the large-scale statistical kind, and the personal anecdotal kind), rather than on speculation.
I'd much rather a doctor "waste money" on a test than come up with an incorrect diagnoses based on symptoms only.
[1] "works" is an interesting point because it isn't clearly defined, and usually means different things to different people.
Ever experience of the system is "unique" - there is this mix of human patient with human provider with finite resources with medical knowledge with time. So there are plenty of examples of long waits, bad service, unfavorable outcomes, even death. It's not hard to cherry pick bad experiences here.
No health system will make everyone live forever. Death comes to us all sooner or late. But universal healthcare works in many places in raising the overall standard of public health, without bankrupting people in the process.
Given that its always spending limited money, and only scales at human rates, its far from perfect. But, at least for some, its better than a "health care level based on your wealth" system.
You have Medicaid for the poor, heavily subsidized Obamacare for the people who don't get it through their employer (hello $100/month plan!) and Medicare for the retired.
I mean my cousin in the US whose kid has cystic fibrosis get better care through Medicaid than our other cousin in Canada who can't even get access to the latest drugs.
https://www.verywellhealth.com/your-assets-magi-and-medicaid...
That $100/month plan will include high deductibles and copays. A weekend visit to an urgent care for a kidney stone will still cost a couple hundred dollars out of pocket.
The U.S. per capita spends far more on healthcare than any other OECD country. We don’t get correspondingly better outcomes or coverage. Universal healthcare is a solved problem within the context that every system necessarily involves some sort of rationing since there aren’t enough medical resources in any country to do otherwise.
If you don’t want to use the phrase “solved system” then don’t but don’t pretend the U.S. is any way better other than in anecdotal instances. Below is a source for information on per capita spending for OECD nations. You can easily find information on health our outcomes, life expectancy, teen pregnancies, infant mortality, etc.
https://www.oecd-ilibrary.org/sites/876d99c3-en/index.html?i...
I’m not sure how your reply has anything to do with what I said.
“Better than the US” is not some hurdle that makes a problem “solved”.
Canada is likely better at snow removal but that doesn’t make it a “solved problem”.
Doesn’t do much for the people disabled from pain on a 3 year wait list for a hip transplant or my buddy’s cousin’s kid who doesn’t get access to the standard of care of CF.
It’s not solved in the least, every country struggles, so using the word “solved” is, as I said, naive.
What goal do you wish to accomplish your pedantic nitpicking? You want to get others to believe that my views on national health policies are naive? You want me to realize that in a strict, mathematical sense of the word saying “solved” is incorrect? These are rhetorical questions because I’m not going to read your response. You clearly don’t know much about policy issues and what it means for a society have essentially “solved” an issue (or have found a decent enough solution that it isn’t a dire problem anymore so that some non pedantic people will say it is solved).
Carry forth Don Quixote on your quest to eradicate incorrect usage of what you think “solved” means.
You claim I don’t know policy without knowing healthcare policy is my day job.
Even given the benefit of the doubt that as an outsider looking in you think it’s solved, but as someone who is elbow deep in it everyday “solved” just sounds naive.
As for socialized medicine it makes doctors another arm of the government. In the UK last week (or the week before) one arm of the government ordered another arm of the government to kill a 9 year old. We are also just outside a 2 year stretch of tyranny of governments all over the world giving that arm of government near unilateral power over our freedom at the point of a gun.
Tell me you don't know what communism is without telling me you don't know what communism is.
Yes, every known communist country has been rife with fascism, authoritarianism, and corruption. But those are orthogonal with communism as an economic model. It's like saying socialism is evil because the Nazis were socialist (they really weren't) just because "Socialist" is part of "Nationalist Socialist Party" .
> In the UK last week (or the week before) one arm of the government ordered another arm of the government to kill a 9 year old.
[citation needed], because this sounds like an extremely gross misinterpretation of a situation, likely done deliberately in bad faith.
Google offers services that you don't pay for in cash.
> Google is also giving health records another whirl. The new initiative, called Care Studio, is aimed at doctors rather than patients. Google’s earlier efforts in this area were derailed in part by hospitals’ sluggishness in digitising their patient records.
Not just digitizing but also in sharing them. Hospital systems are very very reluctant to send out a copy of their records, or even to let you query their system. Especially in the early days of EHRs there was very much a sense that it was their data and they didn't want to let data out because interoperability was a threat to their data moats.
That's good in a privacy sense, but it really did slow down adoption of interoperability initiatives. Finally Medicare/Medicaid basically forced it iirc... if you want Medicare dollars you will send Medicare your encounter data. So now you have to code your records at least good enough to at least get your medicare reimbursements.
> That problem has mostly gone away but another has emerged, says Karen deSalvo, Google’s health chief—the inability of different providers’ records to talk to each other. Dr de Salvo has been vocal about the need for greater interoperability since her days in the Obama administration, where she was in charge of co-ordinating American health information technology. Until that happens, Care Studio is meant to act as both translator and repository (which is, naturally, searchable).
Dead on. It's a hard hard problem though because during the early days we went through a Cambrian explosion in data diversity. Data is often coded very inconsistently or in ways that make it "invalid" to modern schemas. The "miracle of HL7" is basically just a fancy text format, and like the on-table records or XML documents it's still possible to code things in ways that still won't be parseable even if they're syntactially/lexically correct.
There are standardized schemas (f.ex NEDSS schema) available, but they are super over-engineered for a lot of use-cases and can perform quite poorly due to excessive "anything can map to anything" design and field-table-value formats. And again, they suffer from the "there's multiple ways you could code this" thing, just using NEDSS doesn't mean you interoperate with anyone, not close. Not sure what EHRs typically have underneath but it wouldn't surprise me if they all had their own solutions too, EHR software is universally dogshit.
Handling poorly-validated/normalized data from tens of thousands of facilities all doing their own things is a very tough problem, and honestly the only solution is to decentralize it a little bit, facilities have to look at their own data and see if it makes sense the way they're sending it or even if they're storing it wrong. Once it's just another record in a database, if it's not consistent and accurate it likely never will be. It'll just be yet another System-Specific-Record-Identifier in the list for that record, and since it's not coded right nobody will ever be able to read it unless it's patched by someone/some layer.
Data clearinghouses are uniquely positioned to gatekeep that a little bit, and over time there are tools getting written to help various facilities validate their data and see whether it's semantically reasonable. Almost everybody has errors especially if this is their first integration, but they can be brought up to speed on their ongoing record submissions, at least.
I'm sure google would love to be in charge of everyone's health data, or at least to get to see it. Commercial activity isn't notionally allowed but I wonder if HIPAA applies to aggregated data like that, they can probably set up The Business-Purpose Side with a firewall from the Gets To Make Money Querying Anonymized Data side.
It's true that this is a thing where there are intellectual economies-of-scale though. If you can get to One Standard To Rule Them All and actually make it work and not suck, that's useful, everyone just agrees to adopt Google Validation Rules and a shit-ton of terrible mapping/correcting labor gets saved once people get on board. There's just also not really anyone trustworthy enough to handle being the One Giant Repository Of Health Data, Google owning it eventually ends up in massive data mining of sensitive PHI.
Also, it's complex to implement.
Fortunately, we have HAPI [1] and it's very good, but has deployment complexity only a java developer could love.
There's been a couple false starts on a nodejs based FHIR server, but nothing open source and production ready that I've found.
Have you used HAPI FHIR in production at any scale? Our experience is that it completely falls over under any reasonable strain. Try working with a few thousands patents and ~100M Observations and you will see HAPI work very poorly. It's great that HAPI is very feature rich on the API side--they've implemented most of the spec. But JPA and how they're using it is not a healthcare-scale technology. Google's (Spanner based) and Microsoft's (CosmosDB & SQL Sever based) FHIR API are better at scale but have far fewer features. I'm actually ok with that because the FHIR spec's query functionality is actually much more limited. Google's BigQuery integration really helps here. I'm interested to see where AWS is going with Health Lake. In talking with them I believe they have the best paradigm for their technical implementation.
It is a shame that the open source FHIR servers haven't been great. I think they will probably improve once a scalable paradigm for working with FHIR emerges.
FHIR is nice in that you can do uri pointers to external FHIR systems for resources, so it's possible to build up a pretty complex care team and access relationships that way.
I was going down this path and had a lot of it built out, but we ended up changing direction so I never saw it all the way through.
Shame.
At the generalization level, many companies make deals with health providers to get various forms of access to EHRs.
There is huge scope in healthcare for automation, pre-emptive diagnosis and raising the bar for precision.
It is mostly going to be done by a company with good AI chops, I would put my money on Google, from what I have heard about their efforts.
The business logic is broken.
I am not sure what you mean by commercialised.
What it means is I was one step behind :)
As much as I don't like for profit companies monetising this, I am not sure if I know of a better path to innovation.
My cousin has EDS, diagnosing the illness is pretty trivial. It took her 15+ years and when she was diagnosed she was already in severe decline. She could have been diagnosed a decade ago but some doctors just have no interest in googling symptoms and listening to patients.
We have so many smart devices that can record so much data, and it doesn't even have to be auto recording. If you had a headache, if you can mark that and over time based on a pattern it can recommend you to see a specialist or get some tests done.
That just means that for a given region there's only one buyer to deal with.
But no, let's throw billions of dollars at anti-aging instead...
Therefore, an AI that generates good models is valuable.
From the summary:
> The report makes many sound assumptions but also some questionable ones that are overly pessimistic. Yet, overall, its bottom-line estimates should reassure those concerned about the economic feasibility of single payer: The CBO projects that such reform would achieve universal coverage, bolster provider revenues for clinical services, and eliminate almost all copayments and deductibles—even as overall health care spending fell.
0: https://www.healthaffairs.org/do/10.1377/forefront.20210210....
[1] https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?most_...
[2] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
It's the same reason costs to build subway tunnels has dramatically increased in NYC, labor unions have the process by the throat and will accept not even a cent in reduced labor costs, even when improvements would improve safety or efficiency.
Moreover, it's the patient, not the neurosurgeon that has to make the decision to trust the AI.
On the topic of EMR systems in particular, they suck because the people using them hate them and because the people purchasing them, building them, and mandating them aren't the people using them. If it were just a matter of having enough money to throw at the problem, Epic would have done so already.
On the startup and health improve lament side, billing is the rock that so many great ideas break on. It doesn’t matter if the model or business improves care or reduces cost unless it will make a provider more money.
They then use those broken, ineffective programs as evidence of "the governments" incompetence (ignoring the fact they they _are_ the government), bolstering their arguments for rolling back government regulation and spending. This way, private interests are able to dominate the market and the money keeps flowing 'round. I'm convinced this is the mechanism behind both the increasing income/wealth inequality in the US, and the broken state of public infrastructure/services.
The solution is election reform. The data has shown that neither party represents the actual interests of the people, and they only get away with it because of the Game Theory around our election system. Get rid of the Electoral College and FPTP - 1 Person:1 Vote & Ranked-Choice voting would create a cataclysmic shift in US politics in short order.
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-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-washingt...
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.
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/
> 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).
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-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.
https://www.npr.org/2022/01/31/1077155345/california-univers...
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.
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.
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.