FiveThirtyEight had a nice article this week looking at the recent surge in interest in some sort of state-level single-payer health care program, as well as the barriers to that approach. Plus a little foray into looking at the recent state attempts at state-level "public option" plans as an alternative to a larger systemic shake-up.
More States Are Proposing Single-Payer Health Care. Why Aren’t They Succeeding?
The barriers aren't mysterious, they tend to fall into three intertwined categories.
- Regulatory. The biggest challenge here revolves around the fact that most people with private insurance have employer-based coverage, and most people with employer-based coverage are in self-funded plans (i.e., their employer effectively is their insurer, putting aside funds to pay for their health needs). And states can't regulate self-funded plans. That's a big one and would likely require either a very successful persuasion campaign aimed at employers doing business in the state, or more likely some heavy lifting by the state's Congressional delegation to write an exemption into federal law.
- Financial. There's two pieces to this, one of which intersects with the regulatory questions: (1) re-capturing federal money that currently flows into the state via various avenues (Medicare, Medicare, and Affordable Care Act premium subsidies), and (2) raising revenue to capture the rest from the state's tax base. The former requires some deft maneuvering but has some prospects based on various waiver authorities built into federal law, while the latter perhaps requires convincing enough people that their increased tax burden would just offset what they're currently spending on insurance premiums.
- Political. All changes create winners and losers, and it's generally easy to galvanize potential losers against their potential losses than potential winners around their potential gains. The losers could be hospitals, or insurers, or just people who think their tax burden will in fact increase by more than the value of their current premiums. The more a state tries to convince almost everyone they will win, the more generous the promises become and the more concentrated the losses become (galvanizing the losers even more, and leading to proposals more and more people scoff at as unrealistic).
Are these challenges insurmountable for a state? Maybe, but still seemingly less so than first trying to implement a single-payer system at the national level. And arguably some sort of successful state-level implementation
ought to happen before considering any sort of national program. So who'll step up and take the plunge first? California? New York? Massachusetts?
