Building Single Payer Systems in the States with the Senate Bill
One reason I'm less negative on the Senate bill than some is that I know states will continue to build on its framework with improvements -- and most of those states need just majority vote in normally apportioned chambers, so public support for things like the public option actually have a chance to win. And as I mentioned in an earlier post, the bill's Sec. 1332 makes it possible for states to do even more -- combine all subsidies that would normally flow to individuals and businesses into their states into a more integrated alternative state system, even a single payer style approach that goes beyond merely a public option. While states couldn't implement such an approach until 2017 under the law, it still creates a path towards state-by-state movement towards quite radical changes in our health care system.
Many states are already committed to moving towards such universal care systems, but the main thing they need is money-- which federal reform will help make available. While any truly single payer system or similar alternative will still face some ERISA law preemption issues in including all employers, there are a number of approaches involving employer taxes that can encourage their participation.
The federal bill by itself will not be the big-bang singular change many wanted in our health care system, but it will be a platform for innovation -- and money -- to support changes as people keep organizing.
I do believe it is important for states to take the lead in reforming health care. Unfortunately, certain states (barring constitutional conventions) will be at a disadvantage. California, for instance, unveiled a health plan much like the current federal proposal in terms of mandates and coverage, but it failed to gain any traction. The California state constitution is a notorious document that emphasises popular initiatives and judicial wrangling over the legislative process. The legislative process is, in fact, almost irredeemably broken. Therefore, the grassroots would have to pass an initiative that would reform that state's system and manage to be upheld by the courts. This is extremely loaded as we have found out through medical cannabis, gay marriage, and immigration reform. The initiative system could very well rock the boat through federal law if an appeal makes it to the 9th circuit or the Supreme Court. The Jackson/Reagan model of California government is a loaded weapon.
There is also the problem with other states that are bastions of slave market libertarianism that will cater to insurers that provide the worst model of service. These states will harbor these businesses and these businesses will make unreasonable demands on other states... this is what I emphatically did not like about the GOP's proposal to let insurers cross state lines. Federal regulations need to have more teeth in order to contain the beast of monopoly. Large businesses will set up shop in the state that gives them the best benefits in terms of cost and benefits and then mislabel this as competition.
In other words, what you are describing does have some pitfalls that need to be addressed at the local level. California could pass a single payer ballot inititiative, and then God forbid that the Supreme Court strikes it down as unconstitutional and throws the entire process into a black hole. A local progressive lobbying structure needs to be created in order to carry this through to the end.
December 23, 2009 1:09 PM | Reply | Permalink
I agree California could do it.
We tried, Prop.186, in about 1996.
We can try again.
December 25, 2009 7:47 PM | Reply | Permalink
I think you've mentioned this pooling of subsidies here before but... won't it face a lot of opposition from people who get the subsidies? If under the law as passed I'm entitled to some sort of federal government assistance to pay for health insurance then do I really want the state stepping in and snatching by benefit away?
December 23, 2009 1:23 PM | Reply | Permalink
Not if it offers a better deal-- the idea would be for states to combine the subsidies with other additional revenue and cost savings -- such as a public option -- to offer people options far more affordable than subsidies for private insurance.
December 23, 2009 2:17 PM | Reply | Permalink
I love Nathan Newman's warm and fuzzy descriptions of Obamacare!
"...it still creates a path..."
"...it will be a platform ..."
What a wonderful Christmas surprise for the states! A path and a platform!
But outside Nathan Newman's warm and fuzzy little head, bond-ratings for the states are still in the toilet, and stock-prices for insurance companies have hit a 50 year high.
December 23, 2009 3:50 PM | Reply | Permalink
Folks will still be helped. Isn't that what this is all about?
We have to deal with the system as it is because the Repubs have no intention of being part of the reform.
Wake up. All you are going to do is die anyway. And yet, we fight about health care? Who are these Americans think this is a good thing?
December 24, 2009 9:49 AM | Reply | Permalink
It definitely needs to offer a better deal. But that's why you need to give each individual a choice.
December 24, 2009 1:20 PM | Reply | Permalink
One advantage of this approach -- and a danger of the sweeping public option or nationwide single payer system that so many want -- is that there is no guarantee we're going to "get it right" from the get go. That would be the worst possible outcome ... to actually GET what we are fighting for and not be able to implement it well enough to convince others that it's going to work better than the present (non-)system or the imagined alternative they can dream up. Having "laboratories" in several states is going to more quickly identify a structure that actually *works*. Also, if - to pick a number - 10 states make serious efforts in this direction, opposition will at least be split, whereas if it's one nationwide system we were starting to implement next year, *all* opposition (and potential for sabotage) would be focused exclusively on that.
December 23, 2009 3:44 PM | Reply | Permalink
One question Nat, have you ever used the health care system of one of the countrys that have it, like Canada, England or Portugal?
December 23, 2009 8:46 PM | Reply | Permalink
I don't understand how a state can adopt single payer in isolation. Wouldn't everyone with an expensive chronic condition move to the single payer state? If you or your child had an expensive, chronic condition and you were uninsured or under insured, wouldn't you move to obtain health care? I know I would.
For the same reason that everyone has to purchase health care to make the current reform work, all states would have to sign on the single payer reform to make it work. Otherwise, the healthy will opt out and the sick will be disproportionately represented in the single payer states.
December 24, 2009 6:42 AM | Reply | Permalink
Ummm... People with difficulties aren't just going to be able to pull up stakes. And there will probably be resident laws to prevent carpet-bagging and minimize fiscal impact.
You make a decent point, but the truth is more complicated.
December 24, 2009 12:28 PM | Reply | Permalink
Until districts are sanely re-apportioned, Florida will remain a stagnate, if not backward state on every issue. Our legislature is actually advocating off-shore drilling when the bulk of our revenue comes from tourist dollars. They are wholly incapable of taking the long view on anything -- especially health care.
One of the glaring reasons the republican party continues to spin in circles is their aversion to critical thinking and analysis.
Their constituency, by their own doing, is fearful and change-averse. So, republican politicians have no other choice but to rally for the status quo, no matter how bad or destructive.
The good ole boy club rules in Florida -- on health care and everything else. That of which you speak, Nathan, might come to pass in other states, but not here. Not anytime soon.
December 24, 2009 8:48 AM | Reply | Permalink
I would add that states should be able to band together to create an even larger single payer pool. Regional single payers would even be more cost effective than an individual state single payer.
December 24, 2009 11:42 AM | Reply | Permalink
yes, this idea of states combining is crucial. a single or a handful of multi-state systems would be MUCH more likely to lead to national single payer
December 24, 2009 9:29 PM | Reply | Permalink
If you are cheerleading for state centered single payer systems, then why do you need federal money to make it work?
I'll answer it for you. ...because in order for single payer socialism to work, you need to destroy competition amongst the states and competition in general. You need to take away the freedom of consumers and patients to pursue the best healthcare solution for themselves in order for it to work.
Look at Hawaii's Keiki system in 2007. It lasted 7 months before the wheels fell off. Most of the people that were taking advantage of the system could afford to buy private insurance, but abandoned their plans in order to get it for free. And this is from a state that lives off of external infusions on revenue through tourism. How would a state like Mississipi survive such a hare brained scheme? As was noted in one of the above comments, a burdensome single payer plan would cause consumers, businesses and individuals alike to flee to other states. Hawaii was smart enough to ditch their foray in to socialism, before the state went in to cardiac arrest.
I remember Mario Cuomo as governor, griping and complaining that tax cutting states on the otherside of the river and long island sound were "stealing" much needed revenue from his state by luring greedy New Yorkers out of his state. His solution was to call for higher federal taxes and revenue sharing amongst his neighbors. What he meant was "These Governors are kicking my butt, so I'm calling my mommy in Washington to take away your bat and ball and give me your cookies".
If you love state centered single payer plans, knock yourself out. The rest of us can sit back and laugh while you crash and burn.
When your government has a monopoly on violence and a monopoly on the power over life and death, you are screwed.
Face it, the current plan is to take away freedom of choice and centralize control. Oh, I know this usurpation is shrouded in good intentions, but it requires brute force to make it work...and the brute force will become increasingly oppressive as the populace attempts to wiggle and squirm to game the system to get what's best for their families.
December 24, 2009 1:14 PM | Reply | Permalink
Very enlightening post; I was happy to read something very concrete and helpful regarding future issues and potential improvements.
December 24, 2009 2:03 PM | Reply | Permalink
"Ummm... People with difficulties aren't just going to be able to pull up stakes. And there will probably be resident laws to prevent carpet-bagging and minimize fiscal impact."
I don't agree. We are a very mobile society. And when people contract a serious chronic disease, it has to become one of their very highest priorities.
It would be impossible to prevent laws that would be effective against "carpetbagging" unless you restrict those with preexisting conditions, which would bring us back to square one.
People move between states all the time. When they do, they are residents. People have cancer, heart disease, multiple sclerosis, etc., for many years. Of course people with chronic conditions will find a way to move to a state with single payer. People do what they have to do. I see no practical way to implement single payer on a state by state basis.
December 24, 2009 3:10 PM | Reply | Permalink
Won't the lack of a Kucinich Amendment though leave state programs open to challenge in the courts? I would be interested if some real wonk -- or Dennis Kucinich himself maybe -- explaining exactly how (if at all) it will be possible for states to pass single payer.
Also, what possible AMENDMENTS to the national system are possible? My guess is that the insurance companies will quickly find loopholes in the current weak regulatory scheme and start raising rates and finding other ways to cheat customers out of payment for treatment. Then there will in turn be the need for further regulation from Congress, possibly even before the 2010 elections -- to address the evolution of the system BEFORE the mandate and other provisions kick in after several more years.
I would really like to have one of those really wonky wonks on the subject as a guest on TPM Cafe at least after the Senate & House draw up their "compromise" sometime next year.
I am NOT AT ALL convinced that the RW will have any trouble uniting, at least for a time, against the whole measure, as they have now. The very mandate adored by the insurance companies would be the focal point of attack. Newman's rosy political prediction would be a LOT more plausible about a comprehensive single payer system. Ironically, this more 'progressive' or 'radical' policy would be more impregnable to successful RW attack
December 24, 2009 9:37 PM | Reply | Permalink
Single states cannot force pharmaceutical companies to stop bleeding us dry. Nor will they be able to force medical schools to charge reasonable fees for education. And, if single states reduce the gravy train for medical specialists, those are the people who will switch states. This does have to be a nation wide system to reap the true economic benefits that are possible.
Does anyone else understand that cutting the cost of health care will cut the incomes of lots of very well paid individuals, along with corporations? Those very well paid individuals vote, and they contribute substantial sums to politicians - making them more equal than you and I. This may be the major roadblock towards getting our health care costs under control.
December 24, 2009 9:45 PM | Reply | Permalink
Hoppy, you are touching the core of the problem. Health Care should not be an area of our economy that is privatized and left to the "invisble hand" of the so-called "free market." We need fully socialized medicine. None should be allowed to make a profit from health care. We haven't privatized our police forces. Why? Police forces were set up generations ago by our ancestors who clearly understood that the "profit motive" should not be allowed in all areas of our economy. It is a powerful force that produces more goods and services, but when left unfettered it becomes destructive.
Regarding your basic point, though, could not the states buy pharmacutecals from other countries and import more foreign doctors?
Merry Christmas.
December 25, 2009 8:47 AM | Reply | Permalink
If fire fighting was handled the way medical problem fighting is handled, when we have a fire we call our insurance company, who determines if that particular type of fire is covered - if we have had a fire before, but didn't disclose it, we would have to pay the fire fighters ourselves. Meanwhile, the fire department doesn't answer our call until their clerks can determine if our fire is covered, and all of the necessary paperwork is completed. Then, they will have to fight that fire with only the tools that are permitted for our particular type of fire.
The reason the above isn't how it is done here is simple - fires destroy property, and for many years property was only owned by the wealthy, so of course that couldn't be allowed. However, health problems only destroy people's lives, so that isn't really a problem for those who set the rules for our society.
Capitalism is wonderful, isn't it?
December 25, 2009 1:45 PM | Reply | Permalink
Nathan, if these state-based programs could not go into effect until 2017, why not build something else immediately? Why not start a private insurance company which supplies rates based on nothing more than enough-profit-to-go-on. That kind of private company would function identically to the public option -- except that it wouldn't be funded by the government. If there really are enough people interested in creating a cooperative system which supplies universal health care, then there will be enough people to support this kind of company.
December 24, 2009 10:23 PM | Reply | Permalink
Bah, Humbug! What a lovely opportunity to re-invent the assorted wheels that have already been invented in Europe and shown to work.
December 24, 2009 11:50 PM | Reply | Permalink
I agree. But where is the establishment support for such a change? It's nice to say what should be done. But how do you do it?
December 26, 2009 1:15 AM | Reply | Permalink
Without a public option the haters are happy to shoot themselves in the foot. Of course it's just the principle of the issue not emotions that are driving them.
I believe if you did a poll you would find that
those who are screaming kill the bill are also those who voted for Ralph Nader in 2000.
Same irrational thought process, and we know what that got us back in 2000....
December 25, 2009 5:39 PM | Reply | Permalink
The battle will (eventually) be over private, for-profit insurance vs. a national single-payer plan. The bill is a giveaway to your enemies. Only a fool strengthens his opponent before the battle.
I've been voting Democratic for 43 years, and I want to kill the Senate bill and start over. Those of you in favor seem to have no idea how terrible this monstrosity of a bill really is. It's a complete sham that basically gives away the store to the same moneyed interests that have created our obscenity of of a health care delivery system that's all but broken for those who have less.
I'm uninsured, too. This bill will do nothing to help me, as I wouldn't be able to afford insurance, even with a subsidy. The "subsidies" are actually indirect government payments to the insurance companies, of course. Another monumental industry bailout.
The Senate bill is just flat-out wrong. Kill it.
December 27, 2009 11:07 AM | Reply | Permalink
This post makes no sense whatsoever. The Senate bill has absolutely nothing to do with single payer systems. I don't know what is in Sec. 1332, but it doesn't kick in until after 2017, which given the fluidity of the situation might as well be forever.
There is a vast gulf between single payer and the kind of inefficient schemes proposed in Massachusetts in other states. One has cost control; the others have no cost control.
This writer seems clueless and uninformed.
December 27, 2009 6:38 PM | Reply | Permalink
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October 4, 2010 11:52 AM | Reply | Permalink