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Subject: qotd: Public Citizen's roadmap toward state single payer
Date: Wed, 10 Jul 2013 07:51:48 -0700
From: Don McCanne <email@example.com>
To: Quote-of-the-Day <firstname.lastname@example.org>
July 10, 2013
How States Can Get Close to a Single-Payer System
Public Citizen Releases Road Map for States to Achieve Unified,
Universal Health Care; Distributes to State Lawmakers Throughout U.S.
WASHINGTON, D.C. – The steps a state would need to take to move toward
creating a single-payer health care system are somewhat complicated but
are doable, according to a new Public Citizen report that provides
states with a road map of how to achieve unified, universal health coverage.
A state could not hope to achieve a pure single-payer system, such as
exists in Canada, because of federal programs, such as Medicare and
Medicaid. But many of the ambitions of a single-payer system can be
realized at the state level, the report explains. A state can accomplish
much that the Affordable Care Act (ACA), or Obamacare, does not: provide
universal care, greatly increase administrative efficiency and control
Public Citizen distributed the report to state lawmakers throughout the
country through the state affiliates of Health Care NOW. The report is
available (at the link below).
"The facts are simple: We pay far more for health care than any
developed country, yet we cover fewer people and get worse results,"
said Dave Sterrett, health care counsel for Public Citizen's Congress
Watch division. "It's time for real change."
Calling for a universal care system in the United States is often
painted as a quixotic pursuit because of incessant fear-mongering by
conservatives about the supposed evils of a "government takeover" of
But the report, A Road Map to "Single-Payer": How States Can Escape the
Clutches of the Private Health Insurance System, points out that
Americans polled in 2012 were nearly evenly divided when asked if they
favored a single-payer system, and this was amid the relentless drumbeat
of opposition to the ACA. Evidence suggesting support for the
single-payer concept also can be found in Americans' widespread approval
of Medicare, the government-run program that provides nearly universal
care to those over 65 at far less cost than care that is reimbursed by
private insurance companies.
The first step on a state's road to a quasi-single payer system is to
obtain a waiver from the ACA. This is well within reach because the act
includes language that permits a state to receive a waiver from the
ACA's strictures, beginning in 2017. A state can be granted this waiver
if it demonstrates that its alternative would provide coverage at least
as good, for at least as many people, as the ACA would, and not add
costs to the federal budget. For states that receive waivers, the
federal government must provide funds to the state that equal what it
would spend pursuant to the ACA. A state promising to provide
comprehensive, universal care would easily clear this hurdle.
Achieving integration between a state system and Medicare and Medicaid
would be more difficult because the law does not permit a broad waiver
from these programs. But the law does provide ample room for the
administration of these programs within a state to be altered to align
billing systems and prices. This would allow Medicare and Medicaid to
appear to providers and patients to be almost seamlessly integrated with
a state system, although this strategy would require a state to dedicate
resources to reconcile claims with the federal government.
The other major legal hurdle for a state to overcome is posed by the
1974 Employee Retirement Income Security Act (ERISA), which forbids
states from regulating employer benefits plans. But a small body of case
law provides grounds for cautious optimism that the hurdles of ERISA can
be overcome. A state could insulate its system from being struck down on
ERISA grounds by legislating alternative funding options, such as
payroll, income or sales taxes.
The final major hurdle is determining how to pay for a universal care
system. Transitioning from a system largely financed by employer and
employee-paid insurance premiums to one likely financed by some
combination of taxes would be challenging.
But the transition should not hurt employers or residents in the long
run, the report concludes. A proposed system in Vermont, for instance,
would significantly expand both the quality of benefits and the number
of people covered. Yet Vermont's plan would cost slightly less than the
state's current system, according to analysis commissioned by the state.
"Single-payer in the United States has been scorned but never tested,"
said Lisa Gilbert, director of Public Citizen's Congress Watch division.
"We're looking for a few pioneering states with the courage and
fortitude to let common sense prevail over the insanity of our current
patchwork system. Once they succeed, we expect most opposition to
single-payer and our reliance on privately insured health care to become
Report - "A Road Map to 'Single-Payer'" (21 pages):
Comment: This very useful Public Citizen report on steps toward single
payer at the state level serves two important functions:
1) Although the Affordable Care Act is providing a few beneficial
tweaks to the financing of our health care system, by now it is obvious
that, by building on our dysfunctional, fragmented system, intolerable
health care injustices will be perpetuated. Yet Congress itself is
currently so dysfunctional that it is impossible to get them to consider
a vastly superior alternative - a single payer Improved Medicare for All.
For those who cannot wait until we are able to elect a sane
supermajority in Congress, this report provides suggestions on how some
single payer principles could be applied at the state level. Although
that pathway is rugged and cannot lead all the way to single payer, at
least it would provide more improvement than we are seeing with the
Affordable Care Act. There is plenty in this report to keep health
justice activists very busy on the state level.
2) The far more important conclusion to be drawn from this report is
that states acting alone cannot establish a bona fide single payer
system. There are too many major barriers that would prevent states from
totally replacing their fragmented financing infrastructure. Under
current federal laws, limitations imposed on states would not allow them
to capture many of the more effective benefits of the single payer model.
Although states could come much closer to universal coverage, their
systems would still perpetuate many of the inefficiencies and inequities
that exist today. Without the power of a public, single payer monopsony
(a single buyer), improving allocation of our resources would be much
more difficult. Although states could improve billing functions, that
captures only a very small portion of the profound administrative waste
in our system. Any savings on a state level would be very modest and
would not be enough to pay for the elimination of uninsurance and
underinsurance. Total health care costs would increase even more, when
costs are already intolerable.
The lesson? We cannot let up in the least in our efforts to educate the
nation on the imperative of a single payer national health program. To
be unequivocally clear, that's NATIONAL.
We cannot use the example of Saskatchewan and pretend that a state can
set up a single payer system that could serve as an example for the
nation - a model that could be expanded to all states. No. Saskatchewan
began with a tabula rasa. They were able to create a de novo single
payer system. The Public Citizen report shows us that our existing
federal laws create complexities that would prevent states from enacting
a financing model that could be held up to the rest of the nation as an
example of the benefits of single payer, even though that is a noble
intent of the report. In fact, there is a risk that such an effort would
allow opponents to claim, "See, single payer doesn't work."
Vermont is currently implementing legislation that originally was
intended to bring it a single payer financing system. But they found
that a bona fide single payer system is not possible, so they have
abandoned the term, "single payer." That might be wise advice for other
We cannot allow enthusiasm for state efforts to diminish in the least
the exhaustive effort that will be required to reach the threshold of
political feasibility that will be a requisite to motivate Congress to