Essential elements for a successful (US) state-based single-payer HC movement

Great Debates
1

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.

Absolutely Essential

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.

Probably Essential

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.

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There’s a lot I haven’t got to, but I don’t think “A state must have a subdued - or otherwise accepting - SP opposition” is necessary at all. It surely wasn’t for Obamacare, as very nearly 50% of the congress was dragged kicking and screaming to healthcare reform, and that holy war is very much still raging, 6 years later. I don’t see why it would be any different for a state to implement SP. Plenty of states that have single party government with filibuster-proof majorities roll right over the opposition all the time.

3

I’ve seen the idea floated that it’ll only gain root in homogenous population centers because even a lot of liberals don’t like to believe their money is going to the “wrong people.” Vermont is 95% white, so it checks out so far.

4

That is a pretty thorough list. I would list things like what I have below, but I think most are just rehashings of what you said:
**A state with a strong sense of progressivism and willingness to buck trends they deem destructive. **Vermont has been a leader in the US. They were the first state to abolish slavery, the first state to legalize gay marriage and civil unions in the legislature and probably was a first in other areas. States like Vermont seem more adventuresome and willing to buck trends (the way CO & WA made marijuana legal).

**A state where democrats can be held accountable if they just pretend they want single payer. ** This is a big problem in California, the democrats want single payer but only so long as they know it’ll never get passed. When Gov. Schwarzenegger was ready with his veto pen they always got the votes. Once they had the governorship they couldn’t do it. On the national level in 2007 when the dems knew the GOP would filibuster it and Bush would veto it, the dems could easily get EFCA passed in the house. Once Obama came into office and they actually had the power to pass it, they balked. So some kind of accountability so dems who are just pretending can be held accountable, as that false hope gets tiring.
As far as subdued opposition, it really only takes a 10 point net vote for one party or another to have 1 party rule. If the vote splits 55/45 that gives one party supermajority status. So it isn’t like the entire state has to be on board, just so long as 45% are.

I personally think a medicare buy in option is a better option than going straight for single payer. According to William Hsiao, a medicare buy in/public option would provide almost 60-70% of the cost savings of single payer and it would be much less controversial. He predicted health costs would be about 25% lower than expected with single payer, but a strong public option would drive them down to 16% lower, probably because a strong public option would force private insurers to shape up and offer better service or else everyone would take the public option.

Plus with the public option nobody would complain ‘I lost my medical care because of those guys’. No backlash. But a public option still leaves tons of narrow networks, lack of universal coverage, etc. etc. But I think it is a good stepping stone to single payer.

Also there is the issue that single payer saves money. Single payer systems will cost less than our current system. It will cost more in taxes, but overall public & private spending should go down. That could and should be a selling point, but with the strain of anti-statism in the US I don’t know how much of a selling point it will be. As I said earlier, Vermont’s health costs are predicted to be about 25% cheaper than they would be without single payer. Other states like CA, PA & IL have found the same thing when running the numbers.
If I were to make a prediction about the rise of single payer (or at least a medicare buy in) it would start in Vermont, then spread to the rest of new england (which may establish a unified new england single payer system, I don’t know), then spread to the west coast and some of the southwest states. Gay marriage caught on like wildfire. So has MJ legalization and decriminalization.

I have no idea of a timeline. I would hope a few years after vermont’s plan is running and the other states see that not only does it work but that it is cheaper and more humane than our current system, more states might take it up. Hopefully within a decade of that closer to half a dozen states would have single payer (including large states like NY, IL, CA).

5

Not quite. Saskatchewan (and to a lesser extent, Alberta) introduced single-payer universal coverage plans. The federal government of Prime Minister Diefenbaker (from Saskatchewan) then commissioned an inquiry in to health care, chaired by a Supreme Court judge (also from Saskatchewan), who reported back recommending that the federal government implement universal, single-payer health care nationally, by providing the necessary funding to make it attractive to other provinces. Since the amount of federal funding would be large, and paid for out of tax revenue collected by the feds in each province, it was financially not attractive for a province to opt out; an opt-out province would essentially be paying for every other province’s health care.

6

I am in a rush so can’t really Google, but doesn’t Vermont have single payer?

7

State based plans have already been tried and failed in Tennessee and Oregon. They were not exactly single payer but rather plans to provide coverage for the uninsured and poor through Medicaid program changes. They both had to be dramatically scaled back after skyrocketing expenses.For example the cost of TennCare increased from 2.6 billion per year to 8.6 billion in 9 years. That is just for a program that only covers the uninsured. True single payer would cost even more. Vermont is trying to implement single payer and current estimates are that they will have to double the state budget to pay for it. This is unfeasible and will likely force the state to cancel the plans. Tiebout competition will make it impossible for any state to raise enough tax money to implement a single payer system.

8

Emphasis mine. How can you make such an assertion when all the statistics show that all countries that actually have single-payer or its equivalent – without exception – have far lower per-capita health care costs that the US has (on average, less than half the costs)? How can you make such an assertion when the reasons for the cost savings are plainly obvious: the elimination of the vast and costly insurance industry administration bureaucracy, and the ability to directly control provider costs? And what is the point of citing failed experiments that, by your own admission, weren’t really single-payer at all, or even close? Private-enterprise health insurance is the core of the problem, and efforts to work within that system can, at best, lead to only tepid success, if any success at all – and I include the ACA in that assessment. One also has to be careful to consider health care costs in their totality; citing the fact that taxes and government budgets may go up with single-payer is pretty much irrelevant if the extortionate individual payments to private insurance companies disappear entirely.

In my view, one extremely important essential element for enabling single-payer is winning the war on disinformation – being able to neutralize the extremely well-funded disinformation campaigns of organizations like AHIP and, to a large extent, the AMA. The insurance industry lobby group and the AMA are so insidious that they even shamelessly ran major campaigns against single-payer when it was being considered in the Canadian province of Saskatchewan, a jurisdiction that is basically none of their damn business.

Which leads to an interesting question: if the health insurance lobbyists are so convinced that single-payer would be an unmitigated disaster, why are they so terrified of letting the experiment go forward and proving them right? Maybe it’s because in Saskatchewan, and then in the rest of Canada, the experiment went forward and proved them spectacularly wrong, as they knew it would, and now Canada is being cited as a model for a successful single-payer system in a very American-like economy and culture. The truth of the matter is that while AHIP and the industry front groups are self-serving miscreants whose mendacity verges on the criminal, the AMA is mostly ideological and misinformed, just as they were during the Saskatchewan debate. They fear the ability of single-payer to control physicians’ gross incomes, but they don’t see the beneficial effect of physicians getting their invoices paid without having to employ an office full of collection agents and still getting stiffed on half of them. It’s pretty funny actually; I once read a scathing condemnation of single-payer by some activist wingnut physician in Tennessee or someplace, and then the next week his column was lamenting how so many bright young people are being discouraged from the medical profession because of the fiasco of trying to get paid by this unbelievable quagmire of health insurance companies.

As a side note, I highly recommend this book on the powerful and malignant effects of the insurance industry lobby by whistleblower Wendell Potter. It describes what I regard as the core of the health insurance problem in America.

9

Wolfpup, I’d never heard that the AMA got involved in the Medicare debate in Saskatchewan in the early 60s. Knew that the doctors and CMA did. Could you point me to more info on that, please? Thanks!

10

Projections show the cost curve being bent in Vermont due to single payer, and by 2027 health costs being about 25% lower than they would be otherwise. I don’t recall the exact numbers, but instead of spending $15,000 per capita on health costs Vermont will only be spending about $11,400 or so. Hopefully that will come to pass as single payer promotes streamlined administration, price negotiations, removes fee for service pricing and adds transparent pricing.

Also it isn’t like the money you pay in taxes is on top of premiums. The higher taxes will be offset by lower spending by employers and individuals.

I don’t know anything about Tennessee and Oregon’s plans.

11

I’ve heard some medical professionals say 25%= of their time is devoted to insurance paperwork and fighting with insurance companies. If you remove all of that that frees up a lot of physician labor that is not being used efficienctly.

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Wesley Clark, what do you make of my last suggestion that the federal government has to be accommodating & supportive in some way of a state that opts for SP?

I mean, the biggest challenge that VT is facing right now as it gears up for SP is its push for a suitable financing mechanism. However, right now its projections are heavily reliant upon funds from the ACA which are set to be redirected to paying for Green Mountain Care. Could a state such as Vermont still enact SP without the ACA, or, more broadly, a supportive federal government?

Some of the truly affluent states such as CA & NY could surely come up with the $$$ for SP because they’re just so damn wealthy anyway, but I don’t know if the smaller states would be equally as capable.

14

Thanks for the links, Wolfpup. Learn something new everyday!

15

On the cost issues: make no mistake about it, the cost is high. In Canada, the Health Department of each province has the single biggest budget of any department, on average. However, the cost as proportion of GDP is lower, and coverage is universal.

As Justice Hall wrote in his report to the federal government: “The only thing more expensive than full health coverage is no health coverage.”

16

If you look at the reasons other countries spend less on health care is not because of higher paperwork expenses due to private insurance. Administration and insurance are about 7% of healthcare expenses, so if you got rid of all administrative costs then US healthcare costs would still be much higher than other countries. If you look at the growth of health spending other countries expenses are rising just as fast as the US but started from a much lower base. The only way to get US healthcare costs in line with the rest of the world are to invent a time machine and go back in time to cut costs 35 years ago.
Here is a good overview about what causes the overspending in US healthcare http://theincidentaleconomist.com/wordpress/what-makes-the-us-health-care-system-so-expensive-introduction/ If video is more your thing John Green has a youtube video based on that link.

The only way to achieve significant cost cutting is by dramatically cutting salaries of Doctors and nurses and dramatically cutting care. Since much of health care is wasted most of the cuts won’t affect health but some of it will. How will people in Vermont react when they can’t get an MRI but people in New Hampshire can? How will doctors react when those in a neighboring state make 25% more for the same work? They are going to raise holy heck and make it hard for politicians to contain costs.
That is why the experiments in Tennessee and Oregon are instructive. They were targeted toward the uninsured which is a small minority of citizens and who are poorer and less politically active than the average citizen. Yet still costs could not be contained.

From an economy wide standpoint it may not matter whether the costs are being paid by the state government or through insurance premiums, but from the perspective of the state government and the tax payers it matters a great deal. Since they are the ones to the paying that is what matters.
Currently Vermont is 6th in the nation in tax burden at 10.6% of income. In order to pay for Single payer they will have to double their taxes. The state with the highest tax burden is New York with a little over 12% of income. Vermont will have to have a tax burden which is 9 percentage points higher than the current highest burden. The difference between Vermont and New York would be more than the total tax burdens of the state with the lowest burden. It is probably literally impossible for them to raise the burden that much.

17

Projections that the cost curve being bent is another way of saying that we are not going to cut costs but we are going to plan that in the future we will cut costs. If you look at the history of budget projections these future cuts generally never come because in the future politicians will want to be re-elected just as current ones do.
A great example is the medicare doc fix. It was written in the law to bend the cost curve of medicare and would have done a great job, but every year for 14 years it has been postponed and has never actually been implemented.
Both TennCare and Oregon’s plans were projected to be much, much less expensive than they turned out to be.

18

I had a quick look at that and let me give you – for now – just a quick response. It seems for the most part like a reasonably intelligent discussion, and I’m impressed by the reference to Uwe Reinhardt, who is a health care economist at Princeton and someone I have a great deal of respect for. But I will also say that there’s a lot in that blog that I disagree with, and I would venture to say that Reinhardt would, too.

Reinhardt is the originator of what has come to be called Reinhardt’s Irony (or sometimes Reinhardt’s Paradox) and it’s the following. The idea of a government-run health insurance system is often criticized (and feared) by the right on the grounds that it will be excessively bureaucratic, indeed mired in bureaucracy. The irony is that this is exactly backward. A public single-payer system is able to control costs up front by negotiating and regulating provider fees; it therefore doesn’t have to do it at the clinical level of individual patient cases. Payment systems are simple and streamlined and there is zero clinical meddling between doctor and patient. Yet in the private insurance system, the clinical level is exactly where the meddling occurs, and it not only injects the insurance bureaucrats between doctor and patient, but it causes direct and indirect costs that ripple through the entire system in all kinds of different ways. And Reinhardt has said that Europeans (and Canadians) would be appalled and horrified at that level of bureaucratic intervention in their health care.

With that paradigm in mind, I’ll say that one of the things that is misleading in your analysis is that the real amount of these costs is much higher than 7%, especially if compared against the specific costs of direct medical treatment, the hospital and physician costs. A now-dated but still relevant study in the New England Journal of Medicine [PDF file!!] concluded the following:

I will also disagree with your statement that “If you look at the growth of health spending other countries expenses are rising just as fast as the US but started from a much lower base.” There’s actually a good graph on the same site that you linked earlier that clearly illustrates that this isn’t true – the US and Canada started are pretty much the same base back about the time that single-payer got rolling in Canada, and US costs have been rising consistently faster than Canadian costs. And that site also, to its credit, states several times that for all this cost, US health care outcomes are not better than Canada or elsewhere among advanced countries, and sometimes shamefully worse.

And finally, I found this statement in the conclusions intriguing: “Our goal isn’t to reduce our spending to that of other countries. Our goal is to reduce spending so that it is in line with GDP. It’s to get spending down to the curve in the above graph. It’s to get spending down to just the green slice of the pie below…”

Bolding mine. What I found interesting about that is that if you get rid of all the crap that’s been identified – and I will argue that the crap is directly and indirectly all the result of how the system has been structured under private insurance – the “green slice of the pie” represents roughly about two-thirds of current health care spending. The amount that Canada spends per capita on health care compared to the US? Roughly about two-thirds.

19

When I was writing my post I was thinking in the back of my head how Obama said the ACA would cut family costs by $2500, but that never materialized.

So we will have to wait and see. Even if single payer costs the same as existing systems (which I don’t see as likely) it is still a more humane system than our current system.

The guy who created Vermont’s system has helped create many nation’s health systems, so he has worked with many nations who developed working affordable systems.

20

What % of a state’s medical bills are paid by the federal government? I would assume it is about 30%.