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Single-payer healthcare advocates march in a Medicare for All rally in Los Angeles on February 4, 2017. (Photo: Ronen Tivony/NurPhoto via Getty Images)

Single-payer healthcare advocates march in a Medicare for All rally in Los Angeles on February 4, 2017. (Photo: Ronen Tivony/NurPhoto via Getty Images)

Medicare for None: A Response to the State-Based Universal Health Care Act of 2021

Proponents of a state-based universal healthcare approach believe states can be incubators for change, and that ultimately, once one state shows the way, all states will follow—but we have yet to see any evidence of this.

Ana MalinowKay Tillow

The Covid-19 pandemic has laid bare the inequities, inefficiencies, and ineffectiveness of our healthcare system. If there was ever a time for healthcare reform, this is it. But 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: the dream of Newt Gingrich and Ronald Reagan to shrink the federal government.

The U.S. doesn't need to dismantle Medicare, it needs to improve it and expand it to every person.

Based on the historical precedents set by the Affordable Care Act (ACA), the story of Medicaid expansion serves as a cautionary tale to those who’d like to leave healthcare to the states.

On June 28, 2012, the U.S. Supreme Court issued a ruling on the constitutionality of the Affordable Care Act, Congress's attempt to provide near-universal health coverage by mandating individuals and employers to purchase health insurance, expanding Medicaid by lowering eligibility criteria, and widening health insurance protections. The court upheld the constitutionality of the individual mandate but gave states the "option" not to expand Medicaid, calling expansion "unconstitutionally coercive." With this ruling, the Supreme Court opened the door to the balkanization of the ACA: those that expanded Medicaid, those that considered it, and those that would oppose it permanently. It gave the southern states a political out and allowed the further racialization of Medicaid.

Of the original 26 states that brought the case before the Supreme Court, 12, mostly southern states with large populations of color, have not expanded Medicaid, two have passed but not yet implemented expansion, and three only did so last year. A decade after the passage of the bill, these are the states that suffer the worst health outcomes: when compared to expansion states, non-expansion states have seen worse overall mortality rates, more hospital closures, and even higher high school dropout rates. In 2018, states that did not expand Medicaid passed up $43 billion in federal funds.

With the reintroduction of Congressman Ro Khanna’s State-based Universal Health Care Act of 2021, 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 act, which would offer pass-through federal fund waivers, including Medicare, Medicaid, TriCare, Exchange, and federal employee health benefit dollars, to states with a plan to provide comprehensive health benefits to 95% of its residents (defined as citizens or lawfully residing immigrants) within five years, would end Medicare as we know it.

Obtaining a waiver under this act does not set single payer as the model to achieve universal healthcare. In fact, states might choose 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 act would base benefits on the ACA, thus, significant gaps, such as no prescription drug coverage, limited reproductive rights, and no long-term care, would persist. There is nothing in the act that precludes giving Medicare money to private insurance companies, strengthening profit-driven companies to pursue obscene profits and deny care elsewhere. The U.S. would become a nation of 50 different healthcare tiers, at war with each other over federal dollars. States could band into a region to request a waiver application, pitting regions against one another. States unwilling to cover their residents could sit it out, much like the states sitting out Medicaid expansion, creating yet another form of racism and uneven health outcomes. If challenged in court, this new expansion could be ruled "coercive" again, giving some states a political out. But this time, seniors in non-universal states would see their Medicare dollars shunted over to states that provide their residents some form of healthcare. This is the dismantling of Medicare.

Proponents of a state-based universal healthcare approach believe states can be incubators for change, and that ultimately, once one state shows the way, all states will follow. We have yet to see any evidence of this in the U.S., and to bet Medicare on this flawed proposal seems unwise. The Supreme Court ruling set a precedent that states can use federal healthcare dollars as they see fit. Instead of seeing this as the problem, the sponsors of this bill see it as an opportunity to compromise: allow southern states to gut Medicare while allowing more progressive states to "have" universal healthcare.

The U.S. doesn't need to dismantle Medicare, it needs to improve it and expand it to every person. The country must replace its broken, fragmented, profit-driven and racist system with a universal, affordable, accountable, comprehensive, evidence-based, equitable, single-payer national Medicare for all, not Medicare for none. Every resident of every state deserves this. This is something on which we can all agree.


Our work is licensed under Creative Commons (CC BY-NC-ND 3.0). Feel free to republish and share widely.

Ana Malinow

Dr. Ana Malinow has  spent her career taking care of undocumented, refugee, and poor children in Cleveland, Houston and Pittsburgh before moving to San Francisco, where she is currently practicing as a general pediatrician. She is past President of Physicians for a National Health Program (PNHP), an organization of 20,000 health care providers that support single payer national health care.

Kay Tillow

Kay Tillow is the coordinator of the All Unions Committee for Single Payer Health Care, which builds union support for national single payer health care. She lives in Louisville, Kentucky.

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