Above Photo: From Healthoverprofit.org
On February 1, Margaret Flowers posted “Which Path to National Improved Medicare for All?”, which argued that states cannot enact single payer health systems and that a state-by-state approach will not lead to National Improved Medicare for All (NIMA). The article was intended to stimulate debate about strategies to win NIMA.
Kip Sullivan, a single payer activist in Minnesota, responded to some of the points in the article. His arguments were discussed by the Health Over Profit for Everyone steering committee. Below are summaries of Sullivan’s responses and our rebuttals (Sullivan’s full response and the rebuttals are provided at the bottom). Please use the comment section and our Facebook page to keep this discussion going.
Sullivan: Sullivan argues it doesn’t matter that Nancy Pelosi is encouraging single payer supporters to work at the state level. She will use any excuse not to support HR 676: “The Expanded and Improved Medicare for All Act.”
Flowers: It is important for activists to understand how people in power work to maintain the status quo. It is not a coincidence when members of Congress or their allies in the media use the same talking points, they are part of a coordinated effort to divert or divide movements. Pelosi has a platform, and she is using it to send a message to single payer supporters NOT to pursue bills in Congress.
Zeese: The reason this matters is because pressure is building at the federal level where more than half the Democrats in the House have co-sponsored HR 676. Nancy Pelosi wants that pressure relieved, so she tells activists to pass the law at the state level. She knows if pressure builds on Congress, she will be forced to say more than “I have supported single payer since before you were born” and actually do something about passing it. This will only happen if we keep building pressure on Congress. Every Democrat and Republican in Congress should be pressured to endorse HR 676 — that should be the focus of the single payer-NIMA movement, and we should not let Pelosi and other mis-leaders take our focus off the winning strategy for a path that cannot be legally achieved by a state.
Sullivan: In response to the argument that Canada did not have the impediments to single payer in the 1960s that states in the United States face today, Sullivan interprets the argument to mean that Flowers was saying single payer requires a blank slate to succeed.
Flowers: This is a misinterpretation of my statement. I argue that Canada was able to start at the provincial level because their healthcare system is organized at the provincial level. The Canadian government provides funds to the provinces to enable them. They do not have federal laws that restrict them from implementing a health system. The situation is very different in the United States where health care is complicated by a mixture of state and federal programs. Congress would have to pass new laws if states wanted to have access to Medicare dollars or to take over federal insurances such as those for members of the military or federal employees or to replace employer-owned health plans. For these reasons, it makes the most sense to organize for a national health system in the United States, which would have the power to change federal laws.
Stanfield: A major complaint we hear from Canadians seems to be a result of the fact that instead of having a single national plan, Canada has 13 provincial and territorial health care insurance plans. Every province administers the Canadian National Health insurance differently. Since provinces differ in affluence and population density, this creates a problem with inequity of provider distribution, similar to the inequity of access among our state-administered Medicaid systems. A nationally administered system avoids such pitfalls.
If Canada has not been able to consolidate their 13 plans into one, what chance would we have to achieve consolidating a collection of 50 state plans? It would be extremely challenging, to say the least. We can learn from other countries, but we shouldn’t copy aspects of their plans that have turned out to be problematic.
Sullivan: Regarding the Employee Retirement Income and Security Act of 1974 (ERISA), a federal law, Sullivan argues that states can write their legislation in ways that circumvent ERISA, that recent court decisions on ERISA are irrelevant and that ERISA is only a problem if a company sues a state over its healthcare system, which he believes is unlikely.
Flowers: Recent court decisions on ERISA are relevant because they have broadened the basis upon which businesses can prevent states from regulating their insurances. A law cannot circumvent ERISA through language in a bill because the court looks at the impact of the bill. If it restricts businesses’ ability to provide health benefits in any way, then it can be found to violate ERISA. Most people in the United States who have health insurance receive it through their employers and most employers self-insure. Legal challenges to state efforts must be anticipated. They will be prolonged, costly and unlikely to be favorable to the state.
Sullivan: In response to the argument that states must balance their budgets while the federal government does not, Sullivan argues that this is not a problem because states operate at a deficit.
Flowers: Every past effort by a state to enact a universal healthcare system has run into the problem of becoming too costly for states. Each state had to face the choice of dropping coverage for some segments of the population or cutting benefits. This is described well by Drs. Woolhandler and Himmelstein in “State Health Reform Flatlines.” This problem does not exist at the federal level.
The problem at the federal level is not the ability to fund programs, it is the political will to fund them. When it comes to high priorities such as wars or bailing out banks and large industries, the federal government has no difficulty finding the funding. When we have NIMA, the fact that everyone is in the system, including members of Congress and of the wealthy class, will provide an incentive to fund the system.
Sullivan: On the argument that states cannot implement pure single payer systems; and therefore, they cannot achieve the savings of a national system, Sullivan states that Medicare is not a pure single payer system, but it still has value because it controls costs for its population. Sullivan argues that a state could cover the bulk of its population, excluding Medicare, Medicaid and the Veterans Administration, which require federal waivers and changes in law, and achieve similar savings. He calls a public system that insures a particular population single payer.
Flowers: State activists are claiming that they are going to cover everyone in the state under a single system, either using a single trust fund that includes all federal health dollars or using a single “pipe” system where every person in the state has the same insurance card and the state bills the various insurers. The first approach is not possible to achieve because it requires eight different federal waivers or changes to federal laws. The second approach has not been tried before. While it might allow some efficiencies of scale, as Sullivan lists, it will add more bureaucracy at the state level to administer the program. Health professionals and hospitals will still need to interact with multiple insurers for authorizations because the state cannot ban plans for employers, federal employees, members of the military or Medicare Advantage plans.
Zeese: A one-payer system cannot be achieved unless seven federal laws are changed, eight if you count the Indian Health Service (Indigenous peoples are a small population who should have both the IHS and improved Medicare; and therefore, the IHS should continue). For a state to legally achieve a pure single payer, it would need to get waivers for the ACA and Medicaid so the money in those programs, including the billions of ACA dollars going to subsidize the insurance industry, can be used for the single payer program. A state would need Congress to pass laws to amend existing federal laws. This includes Medicare, the VA, ERISA, Tricare and the Federal Employee Health Benefits Law. So, to get single payer at the state level, a state has to go through Congress, HHS and the Center for Medicaid and Medicare Services.
Stanfield: To include Medicare, Medicaid and CHIP enrollees in any state single payer will require federal waivers. While HHS can grant Medicaid and CHIP waivers, an act of Congress is required for a Medicare waiver. Some cite these existing federal waivers for Medicaid as a possible way to divert federal Medicaid money toward state-level single-payer. Some also propose other possible routes to waivers (certain provisions in the ACA). However, all of these are convoluted, speculative, and their success would depend on interpretation of politicians at a federal level.
Even if waivers can be obtained, they pose big risks. Conservative forces in some states will take advantage of loosened federal restrictions on Medicaid, and Medicare to further undermine these programs. For instance, Arkansas took advantage of this process to fully privatize its Medicaid program, allowing higher premiums than federally authorized, and eliminating coverage of non-emergency medical transportation (an otherwise required benefit). Indiana’s waiver includes making coverage effective on the date of the first premium payment instead of the date of application, elimination of retroactive eligibility, and barring certain “expansion adults” from re-enrolling in coverage for six months if they are dis-enrolled for unpaid premiums. A three-month lockout for re-enrollment was approved in Montana.
In fact, there are many examples of extreme inequity already existing among the individual states with regard to health care (esp. Medicaid). Resolving this will require intervention on a federal level.
Sullivan: Sullivan argues that state efforts are better opportunities because it is easier to organize people at the local level and where there are more targets. He says that national campaigns have fewer targets and are farther from home. He adds, “By pulling more people into the fight for single-payer and keeping them involved, state-level single-payer campaigns boost the federal campaign.”
Flowers: I argue that organizers need to be honest with the people they are organizing. Calling state systems “single payer” or “Medicare for All” when the state will still include multiple payers is misleading. When activists understand that a state cannot implement these systems through its own actions but requires Congress to change federal laws, they will feel betrayed.
There are ways to engage people at the local level to work for policies at the national level. We have seen this on a wide variety of issues – stopping Internet privacy bills, stopping Obama’s 2013 attack on Syria, winning net neutrality, stopping the Trans-Pacific Partnership, and so on. Winning NIMA will require a similar mobilization effort focused on impacting the power holders, members of Congress and the administration. Some ways to mobilize people locally are through nationwide days of local actions, resolutions of support at the local level, growing the movement through outreach to various constituencies such as businesses or labor and focused campaigns on members of Congress that include petitions, rallies, bird dogging and lobbying.
Stanfield: While Kip admonishes Margaret for stating that neoliberal corporate-funded politicians (like Pelosi) are only backing state-level single-payer to take the heat off themselves for not pushing for national single-payer, his argument against her statement relies on a flawed assumption. He states,”State action anywhere builds support at the federal level, and vice versa.”
That is only true to a point, and his assertion ignores the fact that we already have a 60% majority of voters who want a NATIONAL universal single-payer modeled on Medicare. We are not starting from scratch. So there is not as much need to grow our movement in terms of getting the average American voter on board. Most are already there! What we DO need to focus on is UNITING all those voters on pressing for the passage of ONE THING, not 50 different things!
Right now people are very confused about what exactly Medicare for All is! The last thing we need is to have 50 different plans to further confuse people!
Kip Sullivan’s full response
(1) Argument: Nancy Pelosi doesn’t want single-payer heard in Congress, so she urges the naïve single-payer advocates to peddle their fantasies at the state level.
My answer: Who cares? Pelosi will grasp at any excuse to avoid doing her part to promote single-payer. In any event, her contemptuous remark doesn’t demonstrate that she supports state action for the reason Margaret stated — that it will reduce pressure on Pelosi and other members of Congress to enact HR 676. It just indicates she doesn’t want to support HR 676. But in the unlikely event she was proposing state-level action in order to reduce support for HR 676, her argument backfires: State action anywhere builds support at the federal level, and vice versa (see more on this below).
(2) Argument: It isn’t true that Canada can serve as a model for the US. In Canada, single-payer was achieved province by province, but single-payer in America won’t be achieved state by state. Margaret quotes Don McCanne, someone I admire but disagree with on this issue:
“Saskatchewan began with a tabula rasa. They were able to create a de novo single-payer system.”
My answer: The argument that single-payer is only possible in a jurisdiction with a “tabula rasa” — a vague term I take to mean a state or country without an entrenched insurance industry and numerous government programs already in place — is an argument against achieving single-payer anywhere in the modern world. If you buy that argument, you should go home and stop trying to tell the rest of us what to do because you’ve already made up your mind single-payer cannot happen anywhere — not Minnesota, not California, not the US. There is no virgin territory left for single-payer systems to spring up in. None of us — not those of us who fight at the state level, not those of us who fight at the federal level, not those of us who fight at both levels — have the luxury of working in “tabula rasa” jurisdictions.
(3) Argument: The Employee Retirement and Income Security Act (ERISA) “is a major obstacle” because it “prohibits states from regulating employee benefits.”
My answer: This might be true depending on how state single-payer legislation is written. The Attorneys General of Ohio and Minnesota issued opinions on this question in the 1990s at the request of single-payer organizations in those states. Both AGs concluded that a state single-payer law that relied on general taxes, for example a corporate income or payroll tax, would not violate ERISA. The AGs said only a state tax that was triggered by the failure of corporations to insure particular employees would violate ERISA. Granted, this is only two opinions from state AGs, but I’m pretty sure there are no AG opinions saying the opposite. The wisest statement one can make on this topic is that ERISA is a vague law and the decisions about it by the federal courts are also vague and hard to predict and, therefore, no one should say with any certainty that ERISA will or won’t be a problem for a particular state single-payer bill.
Margaret cites a 2016 US Supreme Court case in which the court stated Vermont could not force self-insured employers to report claims data to a database Vermont set up in 2005. This is not a relevant case. No state single-payer bill at the state level I know of proposes to make self-insured employers report data to the single-payer board on how much medical care their employees got. Why on earth would any bill require that? But just in case there are some nutty single-payer advocates out there thinking about tucking a provision into their bill requiring state-mandated reporting by employers, here’s a warning: Don’t do that, and in case you were also thinking about putting peas in your ears, don’t do that either.
My second answer to this argument is that a state single-payer bill will be overturned by the courts on ERISA grounds only if a company with standing sues in a federal court. It’s hard for me to imagine why 3M or General Mills, to take two examples of Minnesota-based, multi-state employers who might sue to overturn a Minnesota single-payer law if the law reduced the financial burden of health insurance for those companies (by, for example, relying heavily on a progressive income tax). If the single-payer law raised either no funds off corporate taxes or raised some funds from corporate taxes and those taxes were lower than the premiums corporations are paying now, what corporation in its right mind would sue? There are some firms out there that might not be in their right minds that would sue solely on ideological grounds, but even an ideologically motivated plaintiff would have to show harm in order to have standing.
(4) Argument: States must balance their budgets, the federal government does not have to do that.
My answer: This is an odd argument. It assumes that the federal government’s ability to go into debt alleviates pressure on Medicare and other federally financed health insurance programs and, conversely, that the states’ inability to go into the red prevents states from financing health insurance and other programs. Neither portion of that statement is true. If the necessity of a balanced budget were fatal or detrimental to state-level programs, how is it that states have financed myriad expensive programs ranging from transportation to Medicaid to national guards to schools since the nation was formed?
(5) Argument: States can’t enact “pure” single-payers, ergo, they can’t achieve “the bulk” of savings achievable by a “pure” single-payer.
My answer: Margaret doesn’t tell us what she means by “pure.” I assume she means an impure single-payer is one administered (at any level of government) that does not include every citizen within that government’s jurisdiction. By this definition, Medicare would be an impure single-payer because it insures only 15 percent of the US population and, because it doesn’t insure the other 85 percent, it can’t achieve “the bulk of the savings” achievable by a pure national single-payer (one which covers all 330 million Americans).
This is a true statement: Medicare is not an ideal single-payer for several reasons, one of them being it covers only the elderly and some of the disabled. And because it doesn’t cover everyone, it can’t cut costs as effectively as a Medicare-for-all system would.
But is that any reason to oppose creating Medicare in the first place? Of course not. Medicare is the nation’s most efficient insurance program, public or private. (That reputation is, of course, being endangered as we speak by managed care proponents and privatization buffs, but that’s not an issue relevant to this discussion.) It has not only cut costs because it is a (less than ideal) single payer, but it has reduced suffering for millions of elderly and disabled Americans. (Note that I’m not arguing for any old incremental reform. To be worth fighting for, an incremental reform like Medicare should move us away from the profit-driven multiple-payer system and toward a government single-payer system. Medicare did that. The same cannot be said of the Affordable Care Act. It has reduced suffering for millions of people, yes, but it moved us in the wrong direction — it helped entrench the insurance industry even more deeply.)
At the Minnesota level, an impure single-payer is presumably one that covers only the 4 million Minnesotans who are not in one of the federally financed programs, namely Medicare, Medicaid and the VA. Minnesota might well fail to get the federal government to allow Minnesota to merge those three programs into a state program and thereby cover all 5.2 million Minnesotans in one program. Does that mean a single-payer for 4 million people could not cut costs with the standard single-payer tools:
*replacing the insurance industry and wiping out all their extra admin costs,
* setting hospital and nursing home budgets,
* negotiating fees for doctors,
* negotiating price ceilings on drug companies and equipment manufacturers, and
* exercising more intelligent control over spending on capital facilities like ERs and MRIs?
Of course not. A state single-payer could achieve substantial cost containment.
Could a state cut costs as deeply as a national single-payer? Of course not. Smaller states in particular are at risk of being unable to achieve substantial cuts in both prices and administrative waste, in part because their negotiating leverage with drug companies and providers will be less, and in part because their providers will treat an above-average percent of tourists and workers from surrounding states and they will have to bill for those patients. But arguing against less-than-ideal single-payers at the state level is the equivalent of arguing that Medicare should never have been enacted because it was an “impure” single-payer. Yes, Medicare is impure — it failed to incorporate Medicaid, the VA and all privately insured Americans in one fell swoop. But will anyone to the left of Ted Cruz really argue we should never have enacted Medicare for any reason, much less that it isn’t a “pure” single payer?
Fomenting debates about whether a single-payer can be a single-payer if it doesn’t merge all insurance programs into one is a waste of time. Yes, let’s debate how effective a smaller single-payer can be versus a larger one, but let’s ignore those who tell us states can’t enact single-payers.
If we’re going to worry about the integrity of the “single payer” label, let’s focus our ire on those who seek to bestow the label on multiple-payer bills — bills that leave in place the insurance industry or insurance companies dressed up as something new (“integrated delivery systems” and ACOs). There are those on the right who refer to Obamacare and Bill Clinton’s 1993 Health Security Act as single-payer proposals, solely for the purpose of inducing their base to oppose those proposals. And there are those on the left who refer to multiple-ACO/HMO bills as single-payer legislation in order to induce their base to support those bills. It’s the latter bills that pose the greatest threat to the integrity of the “single payer” label. Vermont Governor Peter Shumlin’s proposal, for example, was not a single-payer bill. It was a three-ACO/HMO bill. Yet since Shumlin announced he was withdrawing his support for his multiple-payer bill, the media has been filled with reports that “single payer failed in a blue state like Vermont.” Similarly, SB 562 in California is not a single-payer bill. Its supporters openly admit HMOs will continue to function under SB 562 (go to page 6 of this document about SB 562 and see the answer to the question, “Is there a role for Kaiser Permanente….?” http://www.healthycaliforniaact.org/wp-content/uploads/SB-562-QA-Flyer.pdf ) And yet SB 562’s supporters and critics routinely refer to it as a single-payer bill.
(6) Argument: State-level campaigns for single-payer drain energy away from the fight for HR 676 at the federal level.
My answer: This argument ignores a fundamental rule of good organizing: People’s organizations (as opposed to organizations that merely ask for contributions) thrive on action (cf Saul Alinsky’s Rules for Radicals). As a general rule, it is harder to keep people involved in an organization when the targets are few and far away, and easier when the targets are numerous and closer to home. A fight limited solely to enactment of federal legislation presents fewer targets and, therefore, fewer opportunities for action, than a state-level campaign, and even fewer than a campaign focused on both state and federal lawmakers. By pulling more people into the fight for single-payer and keeping them involved, state-level single-payer campaigns boost the federal campaign.
Lee Stanfield’s full response:
* As Ralph Nader points out, passage of Traditional Medicare to cover the elderly, “vented out” the elderly activists, which is a big reason the movement for universal coverage did not achieve its goal long before now. He is not implying in any way that Medicare is not a worthy accomplishment. He is simply saying that any time you try to accomplish a sweeping comprehensive movement (such as universal health care) in a “piecemeal” fashion, you “vent off” a portion of the steam that is needed to fuel the movement. That is not an indictment of Medicare. It is an indictment of any further “incrementalist” approaches to national universal single-payer healthcare.
Nader says that if he had tried to do automobile safety standards in an incremental manner, it would never have succeeded. He advises that whenever we have “a solid change that is long overdue and a majority of the people” we shouldn’t try to do it incrementally. We currently have all these things… “a solid change”, “long overdue”, and a strong “majority of the people”.
The point is that an incremental approach gives the opposition too much time and opportunity to focus the full strength of their enormous wealth and power on defeating each small step along the way (in this case each state-level plan) thus dividing and diluting the national movement… slowly sapping our energy and ability to endure.
* Canada in the 60s was much different than the U.S. today. Saskatchewan had a socialist government for many years before passing and implementing universal health care.
The Health Insurance Industry back then was nothing like today’s mega-corporations, so we must be very careful about drawing lessons from Canada’s history.
In addition, a major complaint we hear from Canadians seems to be a result of the fact that instead of having a single national plan, Canada has 13 provincial and territorial health care insurance plans. Every province administers the Canadian National Health insurance differently. Since provinces differ in affluence and population density, this creates a problem with inequity of provider distribution, similar to the inequity of access among our state-administered Medicaid systems. A nationally administered system avoids such pitfalls.
If Canada has not been able to consolidate their 13 plans into one, what chance would we have to achieve consolidating a collection of 50 state plans? It would be extremely challenging, to say the least. We can learn from other countries, but we shouldn’t copy aspects of their plans that have turned out to be problematic.
* To include Medicare, Medicaid and CHIP enrollees in any state single payer will require federal waivers. While HHS can grant Medicaid and CHIP waivers, an act of Congress is required for a Medicare waiver. Some cite these existing federal waivers for Medicaid as a possible way to divert federal Medicaid money toward state-level single-payer. Some also propose other possible routes to waivers (certain provisions in the ACA). However, all of these are convoluted, speculative, and their success would depend on interpretation of politicians at a federal level.
Even if waivers can be obtained, they pose big risks. Conservative forces in some states will take advantage of loosened federal restrictions on Medicaid, and Medicare to further undermine these programs. For instance, Arkansas took advantage of this process to fully privatize its Medicaid program, allowing higher premiums than federally authorized, and eliminating coverage of non-emergency medical transportation (an otherwise required benefit). Indiana’s waiver includes making coverage effective on the date of the first premium payment instead of the date of application, elimination of retroactive eligibility, and barring certain “expansion adults” from re-enrolling in coverage for six months if they are dis-enrolled for unpaid premiums. A three-month lockout for re-enrollment was approved in Montana.
In fact, there are many examples of extreme inequity already existing among the individual states with regard to health care (esp. Medicaid). Resolving this will require intervention on a federal level.
* While Kip admonishes Margaret for stating that neoliberal corporate-funded politicians (like Pelosi) are only backing state-level single-payer to take the heat off themselves for not pushing for national single-payer, his argument against her statement relies on a flawed assumption. He states,”State action anywhere builds support at the federal level, and vice versa.”
That is only true to a point, and his assertion ignores the fact that we already have a 60% majority of voters who want a NATIONAL universal single-payer modeled on Medicare. We are not starting from scratch. So there is not as much need to grow our movement in terms of getting the average American voter on board. Most are already there! What we DO need to focus on is UNITING all those voters on pressing for the passage of ONE THING, not 50 different things!
Right now people are very confused about what exactly Medicare for All is! The last thing we need is to have 50 different plans to further confuse people!
* If a state passes a bill labeled “single payer” and it fails to deliver the savings and quality long promised to the public by proponents of a national plan, or if it fails for whatever reason, then our powerful wealthy opponents will quickly saturate the media with the message that no single-payer plan will work. Sadly history has proven that the public will believe it.
While some states may act on the example to move forward with their own state-wide single payer, others will move backward. The Medicaid expansion disaster showed us the extreme vulnerability of people in those states who chose to take a backward step. Some of the poorest states (which are mostly Republican-controlled) chose to forego federal funding, and instead gutted their Medicaid programs. It is just not ethically acceptable to leave behind the most vulnerable and most needy in some states, while others advance.
* Another issue is that there will be no portability of health care from state to state in a state-level system. It could even spur large migrations of people needing health care, to move from states with no single-payer, to states with single-payer, thus overwhelming the latter with large numbers of higher-costing beneficiaries. Since, as Margaret said, states (unlike the federal government) have to balance their budgets, this scenario would be a nightmare for them.
* A state-level single-payer healthcare plan cannot bring in the large-scale savings of a national plan, because most states do not have large enough populations and economies to generate such a savings. California is an exception, because it has an enormous economy. However, a CA law passed in 1988 requires 40% of all state tax revenue to go to K-12 education. So to raise enough money to fund single-payer, you would have to raise twice as much, because half must go to education. This law would need to be repealed or drastically changed. These kinds of political challenges have derailed the idea of a California single-payer plan for the near future.
Kevin Zeese’s full response:
I appreciate that people are trying to think through the best strategy to achieve national improved Medicare for all (NIMA) and, particularly, the question of whether we focus on individual states or focus on Congress. We can win NIMA, but it requires the movement to be unified and focused on the solution, which can only be achieved at the national level. If some take a different path of pursuing state-based reform without realizing it requires amendments or waivers to eight federal laws, they will waste years of effort that should be focused on building the campaign for a federal law.
We understand the temptation to work at the state level — it seems easier, that is how Canada did it and a state could be a model that shows single payer works. The problem is single payer on the state level is LEGALLY impossible to achieve by a state on its own. As a result, when a state passes such a law, they will end up with a state health program, which will be one more insurance added alongside of the existing health system, making it more complex, bureaucratic and costly.
In the end, a state law is really a multi-payer law trying to achieve universal coverage. When it is inaccurately called single payer and fails, then the media reports that single payer failed, single payer was too expensive, single payer cannot be done. We have already heard this from efforts in Vermont, Colorado, California and New York, even though none of these states could have legally enacted single payer and were not really single payer bills. None of these reports are accurate and each of them hurts our cause.
Attempting single payer at the state level is a mistaken path for multiple reasons. There are eight federal laws that prevent a state from enacting single payer. That is one reason why the Canadian model of starting with a province cannot be applied in the US. It might have been a path for the US in 1965 because these eight laws were not in the way of a state putting in place single payer. That is what is meant by tabula rasa in this context, i.e. a clean slate. We have a complex slate of federal laws, not a clean slate as existed more than 50 years ago. Canada and the US are different in other ways, but this is a fundamental difference that makes the Canadian approach impossible to replicate in the United States.
There seems to be a misunderstanding of what a ‘pure single payer’ means. Pure single payer simply means having one-payer with everyone in one system. Having only one-payer is what makes single payer efficient and affordable. Everyone is in the same system — every patient, every doctor, hospital and provider. That is why single payer has administrative costs of under 5% while our current system has administrative costs that amount to one-third of healthcare expenditures. That includes the costs of the insurance industry and the cost to providers of dealing with the insurance industry.
A one-payer system is what cannot be achieved unless seven federal laws are changed, eight if you count the Indian Health Service (Indigenous peoples are a small population who should have both the IHS and improved Medicare; and therefore, the IHS should continue). For a state to legally achieve a pure single payer it would need to get waivers for the ACA and Medicaid so the money in those programs, including the billions of ACA dollars going to subsidize the insurance industry, can be used for the single payer program. A state would need Congress to pass a law to amend existing federal laws. This includes Medicare, the VA, ERISA, Tricare and the Federal Employee Health Benefits Law. So, to get single payer at the state level, a state has to go through Congress, HHS and the Center for Medicaid and Medicare Services.
In considering this path, it is not even advisable that we seek an amendment to Medicare to allow a state to incorporate it into a state health program. That would be the beginning of destroying the most effective part of US healthcare as it would open the door for other states to privatize it and let Medicare dollars be spent on waivers to buy private insurance. It is a path we should not even pursue as both corporate parties, many Republicans openly, and many Democrats deceptively, want to see Medicare privatized to enrich their donors in the insurance industry.
The reason this matters is because pressure is building at the federal, level where more than half the Democrats in the House have co-sponsored HR 676, the Expanded and Improved Medicare for All Act. Nancy Pelosi wants that pressure relieved, so she tells activists to pass the law at the state level. She knows if pressure builds on Congress, she will be forced to say more than “I have supported single payer since before you were born” and actually do something about passing it. This will only happen if we keep building pressure on Congress. Every Democrat and Republican in Congress should be pressured to endorse HR 676 — that should be the focus of the single payer-NIMA movement, and we should not let Pelosi and other mis-leaders take our focus off the winning strategy for a path that cannot be legally achieved by a state.
Finally, our movement needs to be united in our focus to make NIMA the law. If states where there is the highest level of support for single payer take the legally impossible path of pursuing state single payer, then some of the most important states for national single payer have been lost as they are working on a state, not national, solution. They will be taken off track for years and end up with a multi-payer system in their state.
We can achieve NIMA but we need everyone to have a common strategy and focus to win.