The fight for single-payer health care moves to the states

“The 360” shows you diverse perspectives on the day’s top stories and debates.

What’s happening

A proposal that would make California the first state in the U.S. with a single-payer health care system passed a significant legislative hurdle last week, setting up a crucial vote in the state Assembly later this month.

If enacted, the plan would eliminate private health insurance and move all California residents to a new, state-run insurance program called CalCare funded by new business and payroll taxes. CalCare would be similar to Medicare for All, a proposal for a nationwide single-payer that has gained support among progressive lawmakers in recent years and was a centerpiece of Vermont Sen. Bernie Sanders’s bid for the Democratic presidential nomination in 2020.

Single-payer — so named because a single entity, the government, would pay for all health care — has been promoted by advocates for decades, and public support for a national government-run system has increased over the past few years. But federal action on single-payer is close to unimaginable for the foreseeable future. President Biden, a significant share of congressional Democrats and every Republican member of Congress all oppose the idea.

That stalemate in Washington has shifted the debate to the states. In addition to California, lawmakers in New York, Massachusetts and more than a dozen other states have proposed bills to establish statewide single-payer. These efforts have looked promising at certain points, but no state has ever enacted its own single-payer system. Vermont’s Legislature actually passed a bill to do so in 2011, but the plan was abandoned three years later after the state government failed to find a way to fund the program.

Why there’s debate

The arguments for and against a national single-payer system are well established at this point: Supporters say ditching private insurance would save both lives and money, while opponents warn of massive tax increases and care rationing. Shifting the focus to the states, though, changes the parameters of the debate.

Advocates say states are an ideal place to start single-payer health care. They argue that progressive policies are more likely to pass through state legislatures in blue states, many of which are much further to the left than Congress and are free from procedural hurdles like the filibuster. Backers also point to a number of studies that suggest that though they would require tax increases, single-payer systems would ultimately be cheaper for a state’s residents than the current system.

Conservatives generally argue that the shortcomings of single-payer systems don’t disappear when shrunk to the state level. In fact, they say, smaller state budgets and limits on deficit spending make the idea even more untenable. Others point out that states have their own unique procedural roadblocks that may stifle single-payer efforts — California, for example, would have to have its funding plan approved by voters. There are also concerns among some progressives that the pursuit of state-level single-payer could undermine efforts to enact the system at the national level.

What’s next

It may be years before the fate of California’s single-payer proposal is known. If the state Legislature approves the plan, which is far from certain, the issue would then be put to voters, likely in 2024.



There may finally be the political will to enact single-payer health care at the state level

“It’s well understood that the obstacles to enacting single-payer health coverage in California, as in the country as a whole, arise less from policy than from politics.” — Michael Hiltzik, Los Angeles Times

The pandemic has made the case for universal health care more potent

“If we want to protect people from the next disaster or pandemic and ensure that healthcare is a human right, our legislature has this unique opportunity to make history in our great state. Let’s not allow our traumas, sacrifices and losses to be in vain.” — Keriann Shalvoy and Judy Sheridan-Gonzalez, City Limits (New York)

States could create the pathway for a national single-payer system

“In short, small-scale policy innovations can kickstart widespread adoption on a national level. Enacting a single-payer system on the state level could overcome the legislative and political hurdles that currently impede its implementation on a national level.” — Casey Buchholz, Stephanie Attar and Gerald Friedman, Jacobin

The idea that voters are desperate to keep their private insurance is a myth

“If you’ve been part of the larger conversation, though, you are also likely to have heard a talking point along the lines of ‘But people love their health plans.’ … What Americans like, overwhelmingly, is their public health insurance. What they find inefficient and costly — and what the health care giants are desperate to keep propping up — is a megabillion dollar private insurance industry that consistently ranks below every public option available to consumers.” — Mark Kreidler, Sacramento News & Review

Some U.S. states have larger economies than countries that effectively run single-payer

“It sounds too good to be true but in fact, New York would be joining every other rich nation in the world, all of which already provide guaranteed health care regardless of employment status and whose systems protect public health, not insurance company profits.” — Lori DeBrowner, Daily News (New York)


States face many of the same barriers that hold back national health care reform

“Even with overwhelming Democratic majorities in both legislative houses, it may be difficult to advance the [single-payer plan], since they will face very stiff opposition from private employer groups … and much, if not most, of the current health care industry. There are, moreover, some serious practical hurdles.” — Dan Walters, CalMatters

Blue state lawmakers have no intention of actually enacting single-payer health care

“Democrats like to go on record supporting single-payer healthcare given that it’s a core demand of progressive groups, but even they aren’t about to pass a law that lacks an independent fiscal analysis or a non-laughable funding mechanism.” — Editorial, Los Angeles Daily News

States don’t have the capacity to run a massive health care system on their own

“The lawmakers will enjoy their press conferences and overdone speeches about the matter. But they need to ask themselves if the state is actually prepared to take on such a tall task. Anyone who has spent any time looking at the track record of Sacramento knows one thing for certain: this is a bridge too far.” — Editorial, the Sun (San Bernardino, Calif.)

Single-payer plans always fall apart when faced with the reality of what they would cost

“Still, give California progressives some credit for being open about what it will take to pay for such a system. In the past, support for state-level universal health care proposals has collapsed when the cost of the promised benefits became clear. … There’s no such thing as ‘free’ health care, after all.” — Eric Boehm, Reason

Democrats should put their energy into smaller, more realistic reforms

“Bold plans with no chance of passing are a waste of time. We applaud lawmakers who want expanded access to health care. But their energy is best spent on ideas with a chance of being enacted.” — Editorial, San Diego Union-Tribune

A national system is the only feasible way to achieve universal health care

“Some healthcare activists and their progressive allies, suffering from the frustration and disillusion brought on by the refusal of President Joe Biden and Congress to consider structural reform, have accepted this defeat and turned to state-based reform, jeopardizing Medicare across the country. Healthcare is a national responsibility. To palm it off to states is a step backwards.” — Ana Malinow and Kay Tillow, Common Dreams

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