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Medicare For All supporters demonstrate outside of the Charleston Gaillard Center ahead of the Democratic presidential debate on February 25, 2020 in Charleston, South Carolina. (Photo: Drew Angerer via Getty Images)

Medicare For All supporters demonstrate outside of the Charleston Gaillard Center ahead of the Democratic presidential debate on February 25, 2020 in Charleston, South Carolina. (Photo: Drew Angerer via Getty Images)

Ro Khanna Introduces Bill Allowing States to Carve Path Toward Medicare for All

Single-payer systems at the state-level, said one advocate of the new bill, would "demonstrate just how much better they are than our fragmented for-profit healthcare system."

Kenny Stancil

Congressman Ro Khanna received praise from progressive lawmakers and Medicare for All advocates on Tuesday after reintroducing a bill that would provide states with access to the federal funding and regulatory flexibility needed to implement universal healthcare programs.

"If the last year proved anything, it is that universal health coverage is not optional: it's urgent," the California Democrat, a member of the Congressional Progressive Caucus, said in a statement.

"As we continue building the movement inside Congress to pass Medicare for All nationwide, we must also support states that stand ready to provide healthcare for all of their residents while ensuring they have the resources necessary to do so."
—Rep. Pramila Jayapal

Proponents of the new legislation say it would advance the national movement for a single-payer system on a state-by-state basis, especially as the effort at the federal level has been stymied by the Biden administration's vocal opposition to supplanting the nation's for-profit system.

As Khanna's office explained, the State-Based Universal Health Care Act (pdf) would:

creat[e] a waiver to allow states to develop their own plans to provide access to healthcare for all their residents, via access to federal funding streams and regulations flexible enough to support affordable, universal healthcare plans. In order to apply for the waiver, participating states or groups of states must propose plans to provide healthcare coverage for 95% of their residents within five years. After that time, participating states would be required to demonstrate they reached coverage targets and provide a plan to cover the remaining five percent of their population. States that do not reach the 95% target after five years would have to revise their plan to achieve the targets, or risk losing their waiver. Federal technical assistance would be made available for states seeking help in developing and implementing these plans.

In addition, the bill "requires benefits provided under state plans be equal to or greater than what federal beneficiaries receive now." If a state's proposal is deemed acceptable after being evaluated by an independent panel of healthcare experts, the Secretary of Health and Human Services would then approve or reject the waiver application.

According to Khanna, "This is precisely how bold states like California can take the lead in making Medicare for All a reality."

While long-time Medicare for All advocates—including National Nurses United, the Labor Campaign for Single Payer, and Social Security Works—have endorsed Khanna's bill, expanding Medicare is not the only route to universal coverage outlined in the State-Based Universal Health Care Act.

Khanna's office noted that "states will have the freedom to devise their own individual state-based universal healthcare programs, as long as they meet the coverage breadth and depth requirements."

The legislation identifies a variety of possible funding and regulatory avenues that states can take, including: health benefit exchanges; cost-sharing reductions under the ACA; premium tax credit and employer mandate under the ACA; Medicare; Medicaid; CHIP; FEHBP; TRICARE; and ERISA pre-emption provision. 

Khanna's attempt to forge ahead with universal healthcare at the state level is co-sponsored by Democratic Reps. Earl Blumenauer (Ore.), Suzanne Bonamici (Ore.), Jamaal Bowman (N.Y.), Peter DeFazio (Ore.), Mike Doyle (Penn.), Chuy Garcia (Ill.), Raúl Grijalva (Ariz.), Eleanor Holmes Norton (D.C.), Jared Huffman (Calif.), Pramila Jayapal (Wash.), Mondaire Jones (N.Y.), Barbara Lee (Calif.), Andy Levin (Mich.), Joe Neguse (Colo.), Ilhan Omar (Minn.), Chellie Pingree (Maine), Mark Pocan (Wisc.), Ayanna Pressley (Mass.), Jamie Raskin (Md.), Jan Schakowsky (Ill.), Adam Smith (Wash.), Mike Thompson (Calif.), Rashida Tlaib (Mich.), and Bonnie Watson Coleman (N.J.).

The bill elicited praise from many progressives, including Eagan Kemp, Public Citizen's healthcare policy advocate.

"Even before the pandemic, states like California and New York were leading the way in working to create state-based single-payer healthcare systems that would ensure that everyone in the state has access to the care they need," Kemp said in a statement. "The Covid-19 crisis has only increased the groundswell for state and federal action to fix our broken healthcare system by breaking down barriers to care and eliminating the ability of greedy corporations to profit off illness and disease."

"States should be given the authority and funds to create more efficient and equitable single-payer systems to demonstrate just how much better they are than our fragmented for-profit healthcare system," Kemp added. "This bill would do just that."

Last week, Medicare for All advocates debated the merits and drawbacks of sub-federal efforts like Khanna's in a pair of Common Dreams op-eds.

On the one hand, Dr. Ana Malinow, past president of Physicians for a National Health Program, and Kay Tillow, coordinator of the All Unions Committee for Single Payer Health Care, argued that there is no evidence that successful state-based reforms will be widely adopted nationwide. In fact, they wrote, the danger exists that if healthcare is left to the states, "the U.S. would become a nation of 50 different healthcare tiers, at war with each other over federal dollars."

According to Malinow and Tillow, the U.S. Supreme Court's 2012 ruling on the constitutionality of the ACA, which held that Medicaid expansion should be "optional" for states, led to the "balkanization" of the ACA. With Khanna's bill, they argued, "we are about to see a similar balkanization of Medicare, the one national program that guarantees healthcare to everyone over the age of 65."

"The Covid-19 crisis has only increased the groundswell for state and federal action to fix our broken healthcare system."
—Eagan Kemp, Public Citizen

By failing to establish "single-payer as the model to achieve universal healthcare," Khanna's bill opens the door for states to "go the way of the ACA, a mishmash of employer and individual mandates, greater expansion of Medicaid, and more generous subsidies for the exchanges," the pair wrote, adding that this "would end Medicare as we know it."

Writing in response, Philip Caper, a physician and founding member of the National Academy of Social Insurance, agreed with Malinow and Tillow that "a uniform national program of Improved Medicare for All would be the best way to go, on the grounds of simplicity, efficiency, effectiveness, and political sustainability." However, he added, "I see no evidence that the Congress, as it is now constituted, has any appetite to enact anything close to Improved Medicare for All on a national scale anytime soon."

Noting that "there are ongoing efforts in over twenty states to enact universal healthcare," Caper wrote that "the idea of state-level universal healthcare, despite its shortcomings, is a powerful and compelling tool for education and for organizing the power of the people that will be absolutely necessary to overcome the power of the medical-industrial complex."

Caper's perspective was shared by Jayapal, who in March introduced the Medicare for All Act of 2021 and who is also a co-sponsor of Khanna's State-Based Universal Healthcare Act.

"As we continue building the movement inside Congress to pass Medicare for All nationwide," Jayapal said Tuesday, "we must also support states that stand ready to provide healthcare for all of their residents while ensuring they have the resources necessary to do so."


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