State lawmakers leading new charge for single-payer care
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* Mark Barna

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/53/4/1.1/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/53/4/1.1/F1)

People rally in California in favor of 2017 legislation that would have provided single-payer health care for all residents. While that bill was not passed, other plans for universal health coverage live on in California and in states across the U.S.

Photo by Robyn Peck, courtesy AFP/ Getty Images

For many in public health, the ultimate “get” for the field would be achieving universal health coverage. Though work at the federal level has mostly stalled in the quest for guaranteed care for all — which could help allay everything from costs to disparities — some state policymakers are refusing to give up.

Even with years of setbacks, 20 states have legislation and strategic plans for universal health coverage currently in the works. Whether through single-payer coverage, Medicare-for-all or another means, some states have been steadfastly pursuing universal health care for years.

In California, advocates recently relaunched their push in support of CalCare, a proposed single-payer plan that would guarantee health care to all state residents. California has been pursuing single payer for about 80 years, with more than a dozen plans introduced, including two that were vetoed by the state’s governor.

In 2022, the California Guaranteed Health Care for All Act made headway in the state assembly, but died in committee after opposition from the insurance industry. Undeterred, CalCare supporters, led by the California Nurses Association, are rallying to get the legislation in front of lawmakers and have it passed in 2024.

Colorado lawmakers are also exploring universal health care for state residents, introducing H.B. 23-1209, which would direct the Colorado School of Public Health to analyze a path to state-funded health care, in February. New York legislators are working to amend a bill that would establish health care for all state residents, regardless of immigration status. Other states pursuing universal health coverage include Iowa, Missouri, Ohio, Oregon, Pennsylvania and South Carolina.

Much of the American public supports such work, with 57% of adults believing the federal government should ensure all Americans have health care coverage, according to a January Gallup poll. About 47% said health coverage should be provided through the government instead of private insurers.

Some of the recent support may be related to the broadening of health care access and coverage during the COVID-19 pandemic, according to Elizabeth McCuskey, JD, MPH, a professor at Boston University’s School of Public Health and School of Law, whose research focuses on regulatory reforms for health equity.

Thanks to federal and state government emergency response actions, more Americans gained health coverage during the pandemic. Several states expanded Medicaid eligibility via ballot measure, insuring millions of low-income people. In January, a record 16 million people signed up through state health insurance marketplaces, thanks in part to Affordable Care Act subsidies.

During the pandemic, there was “a second wave” of interest in single-payer coverage, McCuskey told *The Nation’s Health.*

McCuskey has played a role in the resurgence, helping Oregon weigh the possibility for statewide health care for all. She was an advisor on Oregon’s Joint Task Force on Universal Health Care, which offered recommendations to state officials in the fall. In 2022, voters amended Oregon’s constitution to reflect that “cost-effective, clinically appropriate and affordable health care” is a fundamental right that the state must ensure access to, opening the door to new work on the issue.

In February, the Oregon legislature passed a bill that established the Universal Health Plan Governance Board. Members are now working to design a structure for a universal health care program and assess whether the state is ready for such coverage.

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At a 2017 New York City protest, health advocates show their support for single-payer care. The state legislature is considering a single-payer measure that would cover all New York residents.

Photo by Erik McGregor, courtesy LightRocket/Getty Images

## Single-payer plans a popular choice

The means to universal care can be either a multi-payer or single-payer system. Seventeen countries use the single-payer route, including Canada and the United Kingdom.

Single payer is generally one government entity paying for and overseeing all medical care, which is funded mostly by tax dollars. In the U.S., single payer has similarities to Medicare, hence the familiar rallying cry for “Medicare for All.”

Germany, France and other countries with universal care are funded through a multi-payer system using private and public contributions. Multi payer is generally considered a bumpier road because of its complexity.

The U.S. has a multi-payer system without universal coverage, said Erin C. Fuse Brown, JD, MPH, who was also on the Oregon task force. A host of privately owned health care providers, insurance companies and government health programs are stitched together to create an uneven tapestry of health coverage, mostly paid for by premiums and federal tax dollars.

“The actual experience of what you get and how much you pay is vastly different from payer to payer,” Fuse Brown, a professor at Georgia State University College of Law, told *The Nation’s Health.* “It is administratively difficult and it tends to not cover everyone.”

Advocates say single payer is the simplest path to universal health care and health equity, promising less red tape and barriers. In 2020, APHA adopted a policy statement touting the benefits of the single payer approach, noting that the current U.S. health care system is complex, expensive and inefficient when compared to health systems in other wealthy countries. Although the Affordable Care Act has boosted health coverage, more than 27 million people in the U.S. were uninsured in 2021, according to the U.S. Census Bureau.

“Single pay offers not only universal care, but better care,” said Ben King, PhD, MPH, clinical assistant professor at the University of Houston, policy chair of APHA’s Medical Care Section and an author of the APHA statement. “It is the best option to ensure equity, fairness and priorities aligned with medical needs.”

## Costs, tax increases serve as barriers

States are the experimenters of U.S. democracy and often influence federal policy. Massachusetts’ health care system served as a template for the ACA, for example. It is possible the emergence of a successful single-payer state could motivate other states to follow the model and fuel interest at the federal level, experts say. But adopting a single-payer system has been difficult to put in practice.

Vermont came the closest in 2011, one year after the Affordable Care Act was passed. A single-payer system seemed within grasp because the ACA allowed states to create novel ways to finance health care. Vermont’s legislature passed a bill to establish a single-payer plan, but it was never implemented and was abandoned in 2014, in part because of concerns of tax increases.

Vermont needed to raise $4.3 billion in its first year to pay for its Green Mountain Care, which would have meant an 11.5% increase in payroll tax and 9.5% increase in income tax, according to an analysis by Third Way, a policy think tank. Despite the savings that would come from health insurance premiums, co-pays and bills, residents were not on board.

Colorado, with a much larger population than Vermont, would have needed $36 billion a year to pay for single-payer care if a ballot initiative under consideration in 2017 had passed, according to Third Way. Even with tax increases, Colorado’s plan would still have meant a $7.8 billion shortfall for the state budget after a decade.

“I think that’s where a lot of single-payer plans stumble,” Fuse Brown said. “They study it, they model it, but it all comes down to the price tag.”

Still, many long-term cost estimates of single-payer plans indicate that over the years costs decline.

“Evidence shows that given enough time, we will start to see savings,” King told *The Nation’s Health.*

Other barriers exist for states that are pursuing a single-payer system. Among them are limitations on allocation of federal and private health care funds. If a state wants to help fund single payer by re-appropriating federal funding for Medicaid, Medicare and ACA subsidies, approval from the federal government is required.

“Not only does the state have to have the political will to do it, it needs the permission of the federal government,” Fuse Brown said.

Moreover, federal law does not allow states to place mandates or requirements on employer-based health insurance, and states cannot mandate that insurance companies stop selling individual health insurance policies. Both may be needed for a single-payer system.

However, U.S. laws “are not written on a stone tablet somewhere,” King said. “We need the federal government to guide, not just permit, that transition.”

Despite the hurdles, the promise of universal health coverage in the U.S. is hard to let go of, given the profound impact it would have on health and lives.

“The models and the current experience with (the U.S.) system suggest that single payer is probably one of the biggest changes that we could make that would bolster health equity,” McCuskey said.

King said advocates must take action to create conversations on single payer, not only in Congress, but also at the local and state levels. Messaging needs to be fine-tuned, though. For example, the public should understand that the benefits of universal health coverage far outweigh a bump in taxes, and that single payer is a public good for all.

According to a 2022 study by the Yale School of Public Health, a single-payer system would have saved the U.S. nearly $460 billion in 2020, the first year of the pandemic. Over 131,000 COVID-19 deaths and nearly 78,000 excess other related deaths would have been avoided had broader health coverage been in place.

“We really do have to broaden the conversation and make it more approachable for people,” King said. “(Single payer is) effectively simpler, a smaller expense line of government and has the overall advantage of really getting a critical mass.”

## Medicaid expansion in the meantime

Beyond single payer, there are other strong options to improve both health coverage and equity.

One is the so-called “public option,” which gained some traction during the pandemic. The option allows people to buy affordable, comprehensive health insurance from a program overseen by a state, which typically sets health provider reimbursement rates to keep premiums down. With over half of uninsured people in the U.S. qualifying for Medicaid or ACA subsidies, the public option can benefit the people who are left out of other coverage.

Linda Blumberg, PhD, a fellow at the Urban Institute’s Health Policy Center, praised a pair of government actions during the pandemic that were especially impactful: increasing the matching rate for Medicaid to support a higher caseload of customers and offering higher subsidies for marketplace health insurance coverage.

“Those two pieces together did an enormous amount to stop us from facing a coverage disaster that looked like it was going to happen, with this huge recession and so many people losing their jobs,” Blumberg, who is also a research professor at Georgetown University’s McCourt School of Public Policy, told *The Nation’s Health.*

Expanding Medicaid eligibility in every state would also go a long way.

Numerous studies have linked expanded Medicaid to better health, including increases in early-stage diagnosis rates among cancer patients, better access to health care for pregnant women and mothers, increased HIV diagnosis rates, and wider access to mental health care in rural areas.

Overall, 40 states have opted to expand Medicaid eligibility. The 10 lagging states — Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin and Wyoming — are some of the nation’s least healthy. Convincing them to embrace Medicaid expansion would lead to significant public health benefits, Blumberg said.

For more information on state Medicaid expansion, visit [www.kff.org/medicaid](https://www.kff.org/medicaid/).

For more on single-payer health care plans and public health, visit [www.pnhp.org](https://www.pnhp.org) and [bit.ly/aphasinglepay](http://bit.ly/aphasinglepay).

*   Copyright The Nation’s Health, American Public Health Association