This is a topic that I’ve been stewing on for quite some time. Now, I’ve been outspoken on the SDMB about this idea for a while: over the next few decades, single-payer health care systems will materialize in the US; however, they will be entirely state-based, given that the federal level won’t be amenable to SP anytime soon (if ever).
This prediction is borne out by current events, even if the only test case (Vermont) is still a work in progress. In a few years, when Vermont’s system is slated to be up & running, we can all look back on this thread to see which of the following elements were crucial to Green Mountain Care (the state’s moniker for VT SP) getting off of the ground.
With that out of the way, the purpose of this thread is to posit a number of suggestions for essential elements that must exist within a state in order to make the push for state-based single-payer not just a pipe dream CONCEPTUALLY, but rather an actual movement that legitimately succeeds. I’m going to put forward a number of my own ideas & categorize them into three distinct areas - elements which are absolutely essential, probably essential, & those which might be essential - and we can all subsequently debate the merits of my list or otherwise add to it.
1. A state must have overwhelming Democratic legislative control.
In its current incarnation, the Republican Party philosophically & categorically does not believe in universal health care; this largely explains their vehement opposition to the ACA, even though it was their original plan to begin with. Every so often GOP politicians will come out & spill the beans on their categorical rejection of UHC, and it makes their no-holds-barred holy war against the ACA seem slightly more justifiable. Now, that isn’t to say that all Democrats are supportive of single-payer; they’re not, but they’re also conceptually open to government-facilitated health care in general, in whatever form that actually takes.
2. A state must have a supportive grassroots SP movement.
Passing single-payer will inevitably require a strong grassroots movement to influence state legislators. When the ACA was passed, that movement was embodied by HCAN. Nationally, the top SP advocate is still PNHP. In CA, it’s California OneCare. You get the idea.
3. A state must have a subdued - or otherwise accepting - SP opposition.
There will inevitably be an opposition movement to counter the SP advocates; however, they must either be subdued (as in lacking in popular support or power) or otherwise accepting of the results when SP finally passes. There shouldn’t be an all-out holy war against the new program after it has already been passed & enacted.
4. A state must be relatively affluent.
The push for single-payer will surely come up against charges that the state can’t afford to insure everybody, yet that claim will be harder to make if the state is in good shape economically.
5. A state must proactively decide to address single-payer.
As the current fight over the ACA perfectly illustrates, US health care is such an enormously controversial subject that any attempts to improve it legislatively are often stymied or silenced altogether by the heated opposition. Consequently, state legislators must recognize that controversy & decide to pursue SP anyway, often at the expense of other issues. This is an enormously heavy lift.
1. The state’s business community probably has to be on board with SP.
This is one of the arguments that SP proponents always put forward. Health insurance poses such heavy burdens & costs onto US employers that the thinking goes they will inevitably push for SP in order to alleviate much of their overhead & remain competitive internationally. For the most part, this argument hasn’t yet fully materialized, likely because so many of those employers also finance huge HR departments which would be severely weakened in the absence of having to negotiate with health insurers. Because a lot of those HR jobs would be lost in the switch to SP, many businesses might be reluctant to publicly advocate SP even if they’d otherwise prefer it. Still, SP could probably be enacted even if a state’s businesses aren’t entirely supportive.
2. The state’s health insurers probably need to consulted on the switch to SP.
I say that this is probably essential (rather than an absolute necessity) because it’s not altogether farfetched that public sentiments against the insurance industry writ large might turn so negative in the coming years that a state might forge ahead with SP in spite of insurer recalcitrance. Still, it’s likely that the insurance industry will need to be consulted or bargained with in some capacity as a state transitions to SP. If for nothing else, such negotiations might prevent the industry from unleashing buckets of cash on negative advertising that could conceivably jettison the entire effort.
3. The state’s economy probably needs to be in good shape.
This idea mostly goes hand-in-hand with my fourth suggestion in the earlier list; still, the idea behind it is that a state should probably have a decent economy before it attempts to enact SP. In the face of an economic downturn, there’s simply so many OTHER things that a state will first pursue before it ever addresses SP, so a good economic backdrop is probably an essential element.
4. The state’s citizenry probably needs to have majority support for SP.
Again, this goes together with some of my earlier suggestions in the previous list, but I put it in the “probably” category because it’s not farfetched to envision a populace that has a slightly negative reaction to state-based SP (think 55-45% against) eventually coming around to majority support after it finally passes. If there is overwhelming antipathy towards SP, then a state probably wouldn’t pursue it anyway.
5. The state probably needs a Democratic governor.
Again, this suggestion is based on reality: Mitt Romney enacted a UHC system (which served as the basis for the ACA a few years later) in Massachusetts even though he was a Republican, yet his state was still overwhelmingly controlled by Democrats. Consequently, it’s possible (though maybe not altogether probable) that a GOP governor might sign a bill enacting SP in his or her state, provided that that state is hugely Democratic and the veto could perhaps be overridden anyway. Although not every Democratic governor would be welcoming of an SP bill, he or she would be far more likely to sign it than virtually all GOP heads-of-state.
Might Be Essential
1. The federal government might have to be supportive of state-based SP.
As far as I can tell, this is the biggest question mark for state-based SP. Indeed, one of the little-known quirks of the ACA is that it actually enables states to move to alternative insurance frameworks in 2017, provided that these newer systems cover just as many persons as the ACA otherwise would. It’s via this mechanism, in fact, that VT has moved to transition to SP, and it’s questionable whether that state could have done that at all in the absence of government approval or ACA funding. Maybe the hugely affluent states (such as CA or NY) could still move to SP without government facilitation, yet they might conceivably be stymied by the government in other ways depending on federal hostility.
2. The state might need to have a limited ballot initiative or referendum process.
This is the suggestion which most clearly impacts states such mine (CA) that have easily abused initiative & referendum processes. Indeed, I can envision a scenario in which a state passes SP in the state house only to have it taken down via referendum before it ever takes effect. Still, it’s also possible that a state might pass SP in the first place via ballot initiative (this is likely where CA is headed now), so I’m not entirely sure how essential this element would ultimately be.
3. The state might need to see a working example from another SP state.
From my understanding, this is actually how SP got started in Canada: it began in one province and then - based on its initial successes - was eventually adopted across the entire country. In the US, it’s very likely that a similar dynamic is mandated here; simply put, a ton of deep-blue states might decide to sit on their hands until another state moves to SP and it’s proven to be successful there. Ultimately, it’s this final suggestion that might be the most critical in today’s sociopolitical climate; if VT doesn’t successfully pull off SP in a few years, then there’s no telling when state lawmakers elsewhere will take the plunge & enact it themselves.
-Let me know what you guys think. Again, this post is just a framework for many of the broader issues that will certainly be debated over the coming decades. Now, I DON’T doubt that VT is going to have a successful launch of its SP program, just as I don’t doubt that my own state of CA will eventually follow suit along with a slew of other deep blue bastions within the US. The only question is the lengths to which the aforementioned elements will influence the process, and whether additional dynamics might also arise.