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

“The 360” shows you diverse perspectives on the major stories and debates of the day.

What is happening

A proposal that would make California the cleared a significant legislative hurdle last week, setting up a crucial vote in the state Assembly later this month.

If adopted, the plan 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 , a national single payer proposal that has in recent years and has been a centerpiece of Vermont Senator Bernie Sanders’ bid for the 2020 Democratic presidential nomination.

The single payer – so named because a single entity, the government, would pay for all health care – was , and public support for a government-run national system . But federal action on single-payer is close to unimaginable for the foreseeable future. , a significant portion of congressional Democrats and all Republican members of Congress all oppose the idea.

This deadlock in Washington shifted the debate to the states. Besides California, lawmakers in , and have proposed bills to establish a single payer statewide. These efforts have looked promising at times, but no state has ever adopted its own single-payer system. The Vermont legislature actually passed a bill to that effect in 2011, but after the state government failed to find a way to fund the program.

Why there is debate

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

Proponents say states are a great 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 far more left-wing than Congress and free of procedural hurdles like filibuster. Funders also cite a number of studies that suggest that while they would require tax increases, for residents of one state than the current system.

Conservatives generally argue that the shortcomings of single-payer systems do not go away when they are reduced 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 hurdles that can stifle single-payer efforts — California, for example, would have to get its funding plan approved by voters. Some progressives also worry that pursuing a single payer at the state level will undermine efforts to get the system in place at the national level.

And after

It may take years before is known. If the state legislature approves the plan, which is far from certain, the issue would then go to voters, likely in 2024.



There Might Finally Be the Political Will to Adopt Single-Payer Health Care at the State Level

“It is well understood that the obstacles to establishing single-payer health coverage in California, as in the country as a whole, stem less from politics than from politics.” —Michael Hiltzik

The pandemic has strengthened the case for universal health care

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

States could pave the way for a national single-payer system

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

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

“If you’ve been part of a larger conversation, however, you’ve probably also heard a talking point like, ‘But people like their health plans.’ … What Americans overwhelmingly like is their public health insurance What they find inefficient and expensive – and what health giants are desperate to prop up – is a megatrillion-dollar private insurance industry that consistently ranks below all public options available to consumers.—Mark Kreidler,

Some US states have larger economies than countries that actually run a single payer

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


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

“Even with overwhelming Democratic majorities in both legislative chambers, it can be difficult to move the [single-payer plan], because they will face very strong opposition from private employer groups…and much, if not most, of the current healthcare industry. There are also serious practical obstacles. —Dan Walters,

Blue state lawmakers have no plans to enact single-payer health care

“Democrats like to publicly state their support for single-payer health care given that it’s a core demand of progressive groups, but even they aren’t about to pass legislation that lacks an independent tax analysis or non-laughable financing mechanism.” — Editorial,

States do not have the capacity to manage a massive health system on their own

“Legislators will appreciate their press conferences and exaggerated speeches on the issue. But they must ask themselves if the state is really ready to take on such a heavy task. Anyone who’s spent time looking at Sacramento’s track record knows one thing for sure: It’s a bridge too far. — Editorial, (San Bernardino, California)

Single-payer plans always crumble in the face of the reality of what they would cost

“Yet give California progressives credit for being open about what it will take to pay for such a system. In the past, support for universal health care proposals at the state level has plummeted when the cost promised benefits became clear. …After all, “free” health care does not exist.—Eric Boehm,

Democrats should put their energy into smaller, more realistic reforms

“Bold plans with no chance of success are a waste of time. We applaud legislators who want expanded access to health care. But their energy is better spent on ideas that have a chance of being implemented. — Editorial,

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

“Some health care activists and their progressive allies, suffering from the frustration and disillusion caused by President Joe Biden and Congress’s refusal to consider structural reform, have accepted this defeat and turned to reform based on the state, jeopardizing health insurance nationwide. Health is a national responsibility. Passing it on to the states is a step backwards. —Ana Malinow and Kay Tillow,

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