States seek to lead the way on single payer

By Chris Gray
If President Obama and the Democrats in Congress won’t get behind single payer, perhaps there’s a different, more Canadian-style approach to getting universal health care: get a system designed, passed, signed into law and set up in just one state, and the rest will follow. The health care savings for employers in one state could force the other states to fall like dominoes and make the switch.
“I think you always like to push at the national level; that’s where our heart is,” said Dr. Walter Tsou, a PNHP leader in Philadelphia. “[But] We saw at the last debate how hard it is to even get considered. That’s led us to consider a less encompassing approach, and that’s a state-by-state approach.”
Canada’s single-payer system began in a single province, Saskatchewan, and then went national as the other provinces soon saw the fiscal benefit that this approach had to health care delivery. In the United States, California has passed single-payer bills twice, only to have Gov. Arnold Schwarzenegger veto the bills both times.
Minnesota has a strong grassroots campaign that has won the support of that state’s leading Democratic candidates for governor, and other states such as Vermont and Hawaii are moving through economic studies that could crystallize the superiority of a single-payer health care system in the eyes of the American public.
Tsou said the current reforms that passed through Congress will fail in a few short years as the plan proves unaffordable. “It behooves us to find a viable state single-payer system when this system collapses,” he said.
Insurance industry campaigns attack health reform as taking away patients’ choice — of health insurance companies. But Tsou’s associate on the Health Care for All Pennsylvania campaign, executive director Chuck Pennacchio, said single payer can be pitched as the system that is truly “consumer-driven,” in that it opens up the system for health care consumers to have a real choice of doctors and medical care. Under the current system, of course, patients often only have a choice of health insurance companies, if they have any choice or any health care access at all.
Pennsylvania
A single-payer health care bill has gotten traction in Pennsylvania in a way that other states have not, Pennacchio said: Not only does single payer have unanimous support of the Democrats, but at least eight Republicans like it, too.
“What sets Pennsylvania apart from other states is that we’ve been able to get Republican buy-in,” Pennacchio said. “Republican participation is important.”
Pennsylvania House Bill 1660 currently has the support of seven Republicans and all 104 Democrats, while its counterpart in the upper house, Senate Bill 400, has won over one Republican and 20 Democrats. Grassroots activists pushed a state single-payer resolution at a meeting of the Pennsylvania Democratic State Committee, where it received the Dems’ unanimous support.
If the bill passes the Legislature, term-limited Gov. Ed Rendell, a Democrat, has promised to sign the Pennsylvania single-payer measure into law.
Health Care for All Pennsylvania has even more support for an economic impact study. A bipartisan resolution supported by 17 Republicans and 20 Democrats would authorize health care researchers at the Lewin Group to outline the costs, savings and economic benefits of single payer. The study needs to pass just one of two houses of the Legislature and would take about five or six weeks to complete.
But even with such strong support for the study, Pennacchio only puts its chance of passage at 50-50. The Legislature still is working hard to get a budget past for the next biennium, and in election year, he’s not willing to count his chickens before they’re hatched.
Vermont
The chief proponent of single payer in the U.S. Senate is Vermont’s independent Sen. Bernie Sanders. He successfully amended the new federal health insurance law to allow for states to experiment with single-payer systems, but that part of the health bill won’t take effect until 2017.
This could pose a serious obstacle for state single-payer bills. Even if a state is successful at establishing single-payer system, the state law could prove null and void. Such states would need to seek a waiver or the law would have to be changed for the amendment to take effect in say, 2014, when the bulk of the federal legislation is enacted. Sanders has said he is working on a solution to this problem, along with Sen. Ron Wyden, D-Ore.
On the House side, longtime single-payer supporter Dennis Kucinich, D-Ohio, is also working to change this amendment to let states pursue single payer sooner. Activists in several states have been trying to coordinate with his office.
“States will pass this thing — then they’ll go for the waiver,” said Don Bechler, an activist with Single Payer Now, a California group. Bechler said it would be easier to change the law or get the waiver if a state had already made it law. This could convince cautious politicians in Washington to give it support.
Vermont pressed ahead with health care reform, passing a bill on May 12 that will study three health system proposals for the state, including single payer. The bill does not require that any of the three systems actually get implemented, but the Legislature will be given a recommendation.
Former PNHP president Dr. Deb Richter said her current goal is to make sure that the single-payer study is conducted by someone who understands the cost savings of single payer and can give the system a fair shake.
Richter wants the state to hire William Hsiao, the Harvard economist who designed the highly effective single-payer system in Taiwan. The odds are in her favor: Hsiao has testified before the Vermont legislative committees, and he was brought in by Senate Pro Tempore Peter Shulman, who is a leading candidate for governor.
Minnesota
Some of the loudest rhetoric about single payer this fall may come out of Minnesota. The governor’s race is marked by contrast.
On one side, the Minnesota Universal Health Care Coalition has gotten the two leading DFL candidates for governor to endorse the Minnesota Health Act, which provides for a health care system that will cover all Minnesotans.
On the other side, he current governor, Tim Pawlenty, a Republican, is vocally anti-single-payer. In a speech at the state Republican convention that nominated his possible replacement, Pawlenty said the Democratic-Farmer-Labor Party’s noted support of a government-managed universal health care system would ensure its defeat in the fall.
The Republican nominee, Tom Emmer, a state representative, has introduced the Minnesota Health Care Freedom Act, which would ban single-payer health care and perpetuate the for-profit private insurance system. Emmer is a member of the American Legislative Exchange Council, the right-wing, industry-financed national legislative group that has proposed state constitutional amendments that would prohibit single-payer systems in states such as Arizona.
Emmer has even gone so far as to speak out in support of the freedom to stick with private health insurance on the news commentary show “Fox & Friends.”
But PNHP activist Dr. Susan Hasti thinks any attempt for politicians to try to make a campaign issue out of single payer support will backfire.
“I don’t think it’s going to be a negative,” Hasti said. “We can’t tinker with the system; we have to change it.”
Hasti said factors such as the fear of losing health care and the ever-escalating rise in health care premiums have built strong grassroots support for the universal coverage bill.
The sponsors of their legislation have gone up from 62 in 2008 to 74 this year. The bill must pass through a number of committees, and Hasti said it could probably not become law until at least 2012, even with a favorable governor.
Minnesota activists have worked to build the movement, keeping the bill alive until it might be signed into law. As it passed through each committee, this Minnesota coalition has rallied constituents in committee member districts.
“We know we have an uphill battle, but we have made progress,” Hasti said.
California
The Minnesota legislation was initially modeled after a bill that has passed California’s Legislature twice: The California Universal Health Care Act, now referred to as Senate Bill 810.
The proposal by state Sen. Mark Leno, D-San Francisco, authorizes $1 million to establish a commission that would decide how to pay for the system. Voters would then have to approve funding for it through a state ballot initiative.
The San Francisco Chronicle reports, “The proposal, which is estimated to cost $200 billion, would eliminate private health insurance in California and replace it with a state-run system, which would be provided to every California resident. That system would be overseen by a new state agency that also would ultimately decide what services the coverage would entail.”
But activist Don Bechler said the proposal would save $30 billion compared to what Californians currently spend on health care. From the savings, California would spend $22 billion to cover the uninsured and offer more comprehensive care. In the end, the California economy would spend $8 billion less on health care while providing a higher quality and more equitable level of care.
Single payer has passed twice in California; The current version, SB 810, passed through the state senate in January and the bill awaits a third vote from the General Assembly. Gov. Schwarzenegger vetoed both of the first two versions of the bill.
“He’ll probably veto it again,” said activist Don Bechler. “We keep coming back and keep building the movement. Next year, we’ll get a governor who can sign it.”
That governor is likely to be Jerry Brown, a former governor, mayor of Oakland and the current attorney general. Brown has wholeheartedly endorsed single payer in the past, but Bechler said he was now on the fence, citing cost concerns.
The costs of single payer have risen in California since the legislation was first estimated several years ago, but so has all health care. Bechler said his state, like others, needs a fresh economic analysis of single payer to give more weight to the argument that a government-managed system would save money by cutting administrative costs.
Bechler said the grassroots movement has grown, anticipating Brown’s eventual approval of single payer for all Californians. The movement is strongest in the Bay Area of Northern California, so Single Payer Now recently added a new director in Los Angeles. PNHP has also recently hired an executive director for its California chapter.
In some ways, the bill has been easy to pass, since legislators assume Schwarzenegger will just veto it. If bill gets passed next year, California legislators will have to stick behind something that may actually become law. Bechler said this concerns him, but he is not too worried.
“A majority of the Democrats are co-authors of the bill,” he said. “It’s on the Democratic state platform.”
Hawaii
Meanwhile, far off in the middle of the Pacific Ocean, America’s 50th state, Hawaii, could quietly become the first state to have single payer. Hawaii has been at the forefront of progressive health care for decades. Its one-of-a-kind law, the Prepaid Health Care Act, requires that all employers offer health care benefits to employees working more than 20 hours a week.
Thanks to that law, Hawaii already has one of the lowest uninsured rates in the country, but it still doesn’t cover everyone. Not everyone works 20 hours, for instance. And the increased cost of private health insurance has strained employers in Hawaii just like everywhere else.
Last July, the Hawaii Legislature created the Hawaii Health Authority, which has been ordered to study and implement a system that will provide health care to all Hawaiians. The Legislature had to override the veto of Gov. Linda Lingle, who has continued her defiance of the legislation by refusing to nominate members for the authority.
Dr. Stephen Kemble said that supporters will just wait until she leaves office. Her successor is likely to be a Democrat, and at least one of the candidates, former U.S. Rep. Neil Abercrombie, is an ardent single-payer supporter.
HB 1504, which created the Hawaii Health Authority, makes no mention of the term “single payer” anywhere, but Kemble said that’s what he expects to come out of it.
“My best guess for a politically feasible scenario would be that Hawaii would create a single-payer plan” with a nonprofit administrator, wrote Kemble in an e-mail. “That is my dream anyhow.”

Several other states also have single payer bills pending before their Legislatures:

Colorado
House Bill 1273, sponsored by Rep. John Kefalas, was withdrawn in April 2009. Kefalas pulled the measure after it was made apparent that it lacked the support of Democratic Gov. Bill Ritter. Bill had 18 co-sponsors as of February 2009 and passage was hoped by 2011.
The bill was unfortunately derailed after fierce opposition from Golden, Colo.-based Independence Institute and their stealth blog, “Patient Power Now.”
The legislation would have created a 23-member authority charged with making recommendations about how to implement a single-payer health care system to the Legislature and the governor.

Massachusetts
“Mass-Care was launched in 1995 as a coalition of organizations sharing a deep concern about the inequities of our health care system. We now act as the grassroots organizing umbrella for more than 100 groups in Massachusetts, representing over 500,000 residents in the state fighting to make health care a right. Massachusetts HB 2127 has active opposition from the Massachusetts Medical Society, but HB 2127 does have 11 Senate sponsors, 38 sponsors in state House.” (from the Mass-Care, The Massachusetts Campaign for Single-Payer Health Care, website).
Missouri

Missouri Universal Health Assurance Act or SB 18:
“The Missouri universal health assurance program is hereby created for the purpose of providing a single, publicly financed statewide program to provide comprehensive necessary health care services, including preventive screening, for all residents of this state. This program shall have as its goals: (1) Timely access to health services of the highest quality for every resident of the state so that all may benefit; (2) The provision of adequate funding for health care; (3) Lower health care spending through streamlined administration, a single bill, and uniform payments.”
SB 18 only orders a study and has only one sponsor, Joan Bray D-St. Louis.
New Hampshire
N.H. house passed HCR 2, which endorsed HR 676, the national single-payer bill. HCR 2 died in the state Senate.
New Mexico
The New Mexico Health Security Act, HB 339 & SB 281, has been introduced. Current Gov. Bill Richardson (D) does not support single-payer, but State Senator Jerry Ortiz y Pino, a longtime supporter of single-payer health care, is running for Lieutenant Governor. The Health Security Plan is a staged, three-year plan that begins with financing studies and completes with actual implementation of universal coverage.
New York
New York has a state single payer bill in each house, A2356 and S2370. A study ordered by former Gov. Eliot Spitzer was conducted by the Urban Institute and showed significant cost advantages in a single-payer system. Gov. David Paterson has supported single-payer health care but not campaigned for it. The bills also have 76 sponsors, and in the General Assembly, A2356 has had more sponsors than votes needed to pass the legislation. The Senate, until recently dominated by Republicans, has been cooler to its proposal. A resolution passed the lower house, in 2008 which endorsed the federal single-payer bill, HR 676. The Senate, now in the hands of Democrats, similarly endorsed HR 676 in 2009.
North Carolina
Candidate plans to introduce single-payer legislation if elected.
Ohio
Health Care for All Ohioans Act — HB 159, with 17 co-sponsors.
Wisconsin
SB 51 “Healthy Wisconsin” passed in 2007 by Democratic state Senate; failed in general assembly. Governor only openly supported expansion of Medicaid system. Attacked by outside groups such as arch-conservative Wall Street PAC “Club for Growth” and WSJ editorial page. No mention of reintroduced bill in 2009-10 term.
Washington
Washington Health Security Trust Bill was first introduced in the 2007 session, with 23 co-sponsors. The legislation never made it out of committee. The bill was apparently re-introduced in 2009 session, with fewer sponsors, but there was very little action as state maneuvers severe budget crisis.