Activists demand universal healthcare during a march in Wilkes-Barre, Pennsylvania on October 2, 2020.

(Photo: Aimee Dilger/SOPA Images/LightRocket via Getty Images)

The Case for State-Based Single-Payer Healthcare

Throughout U.S. history, states have been the much-needed small laboratories that have succeeded in developing social innovations that eventually went national.

The State-Based Universal Health Care Act, SBUHCA or HR 6270, is a bill designed to make it easier for states to obtain federal funding for state-based universal healthcare initiatives and minimize legal challenges. An opinion article published on April 1, 2024 in Common Dreams was highly critical of this proposal and prompted this response.

The author expresses concern that the phrase "single-payer" does not appear in the State-Based Universal Health Care Act. The omission is intentional. Single-payer remains the goal, but mentioning single-payer in SBUHCA is likely to repel members of Congress who have opposed the Medicare for All Act(s) for decades. Under SBUHCA, advocates who feel that a public option plan or expanding Medicaid is the route to true universal healthcare will find, as confirmed by many studies, that there is no pathway to comprehensive and affordable universal care without eliminating the multi-payer private insurance system. So, while still possible, it's unlikely that states will discover an affordable alternative to meeting the requirements of SBUHCA without removing or minimizing the influence of private insurance.

The article states that Medicare is still our best federal healthcare program and that SBUHCA would end Medicare. State-based single-payer plans can expand Medicare, not end it. President Lyndon Johnson and Congress originally conceived Medicare as a single-payer, universal system. The Southern states strongly opposed it, perpetuating Jim Crow laws. Medicaid was the compromise that ultimately allowed Medicare to pass. There is no question that Medicare, as initially planned, would have been far superior. Still, our nation made progress, and the feds did not permit Southern states to ruin Medicare for the rest of the country. It's time to replace "Medicare for a Few" with Improved Medicare for All. With the expansion of Medicare Advantage (MA) and Accountable Care Organizations-Realizing Equity, Access, and Community Health (ACO-REACH), the Centers for Medicare and Medicaid (CMS) is making things worse. States could do something better and not worse.

Far from diverting attention away from national Medicare for All, state-based single-payer movements energize a national movement that has been stuck in neutral for years.

"States rights" has become a pejorative term, but it's not the utterly negative concept the article claims. Throughout American history, and much more often than not, states have been the much-needed small laboratories that have succeeded in developing social innovations that eventually went national. The primary provisions of the Affordable Care Act, for example, were first formulated in Hawaii and Washington and refined in Massachusetts before being implemented nationally. The same is true for women's suffrage, Social Security, the direct election of senators, the prohibition on indoor smoking, gay marriage, etc. While not all states immediately accepted Medicaid expansion, at least 12 states have expanded it after seeing how well it has worked in other states. So yes, we need to temporarily remove health policy from the federal government and allow states to model something better! State innovation waivers for Medicare have been part of the Social Security Act since 1967. CMS expanded waiver authority in 2010 by creating the Center for Medicare and Medicaid Innovation. By statute, CMMI has broad authority to negotiate innovative programs with states and is willing to discuss options before passing state legislation. Nevertheless, the review process could be more straightforward (as the article implies), and we are still awaiting the first state to apply for a single-payer waiver. However, one to three successful state models should be sufficient to jumpstart the federal movement.

The article is correct in saying that the Canadians had no federal health programs that had to be "busted up" to satisfy the desires of the provinces. Still, the situation was much more complicated than is commonly portrayed. In 1945, newly elected Saskatchewan Premier "Tommy" Douglas had to find a way to provide healthcare to southwest Saskatchewan's farmers after the Depression because lack of healthcare further devastated the province's economy. However, despite Douglas' impressive results over a decade, it took 20-plus years for other provinces to adopt the risky "socialized medicine," and only after a very sympathetic federal government in 1968 expanded its cost-sharing plan with a new tax and a set of principles that provinces needed to follow. The Canadian Parliament later enshrined these principles in the Canada Health Act of 1984, which, while unifying, still allows for considerable provincial variation. In Canada, the feds had to find new money to fund the popular programs. In the U.S., states would ask only to manage the money that the feds are already spending in that state. This history demonstrates that social innovation often arises out of a crisis of necessity and is best tried on a relatively small scale before attempting a national program. Just as in Saskatchewan, U.S. states feel the healthcare crisis today more acutely than does the federal government. This circumstance is why there is so much more action for single-payer at the state level than at the federal level.

If the bar concerning a state's obligations under a waiver is too low, as many have suggested, we must lobby to raise it, not reject the entire bill. We also must demand that the feds enforce federal healthcare laws, not blame the bill as inadequate. H.R. 6270, Section 1335(b) requires that waiver applications provide coverage at least as comprehensive as the federal programs the state universal program would replace. This provision should prevent states from watering down coverage when implementing a state-based universal healthcare program. If an audit indicates the required benefits are not adequately covered, the SBUHCA Medicare waiver for the state could be rescinded and those residents put back on Medicare.

How will the feds wrest control back from the states once a national plan is in place?According to HR 6270, and as consistent with most federal laws, additional enforceable regulations will be issued shortly after the law is passed. Such details as the scope and terms of the waiver and how the periodic reports and evaluations are to be conducted will be addressed in those regulations. However, it is highly unlikely that a state legislature will even want to "keep the money" to maintain a duplicate bureaucracy once a national program is enacted.

The article's author worries that state healthcare funding will have to compete with other state programs, and financing will be unstable. That is why state plans currently include dedicated trust and reserve accounts to fund only health benefits according to statutory guidelines.

Far from diverting attention away from national Medicare for All, state-based single-payer movements energize a national movement that has been stuck in neutral for years. It is much easier to organize and show progress at the state level because people are more motivated to work on the problems they see right before them. State legislatures are often more bipartisan than Congress, and it's somewhat easier to pass new ideas, even if it takes several sessions. There are now at least 19 states actively pursuing state-based, single-payer healthcare, involving hundreds of dedicated activists. In Washington and Oregon, for example, it has been quite exciting to watch legislators get behind and understand the single-payer movement and to see them push our states' congressional delegations in letters and resolutions to support national single-payer legislation even as they work to build universal healthcare locally. State legislatures are often less polarized than Congress. Also, many of our members of Congress have been state legislators. Advocates can orient state-level candidates and elected officials toward single-payer healthcare much more quickly than they can with members of Congress.

Participating directly in the Washington Universal Health Care Commission meetings has also been quite stimulating. To say that this two-track activity is moving us "backward" is not to understand what these states are actually doing. Except for a handful of Northwest Congresspersons, including Rep. Pramila Jayapal (D-Wash.), who was a healthcare champion at home before being elected to Congress, writing the Medicare for All Act of 2019, and sponsoring the SBUHCA in 2018 after Rep. Jim McDermott (D-Wash.) had written it in 2015, it has been much more difficult to find interested federal representatives. Every state activist that we know would much rather move directly to a national program, but the interest and action are just not yet at that level in Congress.

One Payer States, a national organization promoting the creation of a federal, universal, high-quality, and affordable single-payer healthcare system, believes the most likely route leads through the states and strongly supports the SBUHCA. For more information, please go to The authors are all members of One Payer States.

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