Point: Medicare for None: A Response to the State-Based Universal Health Care Act of 2021
Proponents of a state-based universal healthcare approach believe states can be incubators for change, and that ultimately, once one state shows the way, all states will follow—but we have yet to see any evidence of this.
By Ana Malinow, M.D. and Kay Tillow
Common Dreams, May 29, 2021
The Covid-19 pandemic has laid bare the inequities, inefficiencies, and ineffectiveness of our healthcare system. If there was ever a time for healthcare reform, this is it. But some healthcare activists and their progressive allies, suffering from the frustration and disillusion brought on by the refusal of President Joe Biden and Congress to consider structural reform, have accepted this defeat and turned to state-based reform, jeopardizing Medicare across the country. Healthcare is a national responsibility. To palm it off to states is a step backwards: the dream of Newt Gingrich and Ronald Reagan to shrink the federal government.
Based on the historical precedents set by the Affordable Care Act (ACA), the story of Medicaid expansion serves as a cautionary tale to those who’d like to leave healthcare to the states.
On June 28, 2012, the U.S. Supreme Court issued a ruling on the constitutionality of the Affordable Care Act, Congress’s attempt to provide near-universal health coverage by mandating individuals and employers to purchase health insurance, expanding Medicaid by lowering eligibility criteria, and widening health insurance protections. The court upheld the constitutionality of the individual mandate but gave states the “option” not to expand Medicaid, calling expansion “unconstitutionally coercive.” With this ruling, the Supreme Court opened the door to the balkanization of the ACA: those that expanded Medicaid, those that considered it, and those that would oppose it permanently. It gave the southern states a political out and allowed the further racialization of Medicaid.
Of the original 26 states that brought the case before the Supreme Court, 12, mostly southern states with large populations of color, have not expanded Medicaid, two have passed but not yet implemented expansion, and three only did so last year. A decade after the passage of the bill, these are the states that suffer the worst health outcomes: when compared to expansion states, non-expansion states have seen worse overall mortality rates, more hospital closures, and even higher high school dropout rates. In 2018, states that did not expand Medicaid passed up $43 billion in federal funds.
With the reintroduction of Congressman Ro Khanna’s State-based Universal Health Care Act of 2021, we are about to see a similar balkanization of Medicare, the one national program that guarantees healthcare to everyone over the age of 65. The act, which would offer pass-through federal fund waivers, including Medicare, Medicaid, TriCare, Exchange, and federal employee health benefit dollars, to states with a plan to provide comprehensive health benefits to 95% of its residents (defined as citizens or lawfully residing immigrants) within five years, would end Medicare as we know it.
Obtaining a waiver under this act does not set single payer as the model to achieve universal healthcare. In fact, states might choose to go the way of the ACA, a mishmash of employer and individual mandates, greater expansion of Medicaid, and more generous subsidies for the Exchanges. The act would base benefits on the ACA, thus, significant gaps, such as no prescription drug coverage, limited reproductive rights, and no long-term care, would persist. There is nothing in the act that precludes giving Medicare money to private insurance companies, strengthening profit-driven companies to pursue obscene profits and deny care elsewhere. The U.S. would become a nation of 50 different healthcare tiers, at war with each other over federal dollars. States could band into a region to request a waiver application, pitting regions against one another. States unwilling to cover their residents could sit it out, much like the states sitting out Medicaid expansion, creating yet another form of racism and uneven health outcomes. If challenged in court, this new expansion could be ruled “coercive” again, giving some states a political out. But this time, seniors in non-universal states would see their Medicare dollars shunted over to states that provide their residents some form of healthcare. This is the dismantling of Medicare.
Proponents of a state-based universal healthcare approach believe states can be incubators for change, and that ultimately, once one state shows the way, all states will follow. We have yet to see any evidence of this in the U.S., and to bet Medicare on this flawed proposal seems unwise. The Supreme Court ruling set a precedent that states can use federal healthcare dollars as they see fit. Instead of seeing this as the problem, the sponsors of this bill see it as an opportunity to compromise: allow southern states to gut Medicare while allowing more progressive states to “have” universal healthcare.
The U.S. doesn’t need to dismantle Medicare, it needs to improve it and expand it to every person. The country must replace its broken, fragmented, profit-driven and racist system with a universal, affordable, accountable, comprehensive, evidence-based, equitable, single-payer national Medicare for all, not Medicare for none. Every resident of every state deserves this. This is something on which we can all agree.
Dr. Ana Malinow has spent her career taking care of undocumented, refugee, and poor children in Cleveland, Houston and Pittsburgh before moving to San Francisco, where she is currently practicing as a general pediatrician. She is past President of Physicians for a National Health Program (PNHP), an organization of 20,000 health care providers that support single payer national health care.
Kay Tillow is the coordinator of the All Unions Committee for Single Payer Health Care, which builds union support for H.R. 676. She lives in Louisville, Kentucky.
Counterpoint: Let’s Go All Out for Universal Health Care in the U.S.
We should continue to vigorously advocate for a universal publicly funded privately delivered health care system at every level throughout America—state as well as national.
By Philip Caper, M.D.
Common Dreams, June 3, 2021
An article last week by Ana Manilow and Kay Tillow published by Common Dreams sounds a cautionary note about attempts to create state-based universal health care systems, because they will certainly increase the amount of fragmentation in the Medicare program. They are almost certainly right, and more fragmentation is the last thing we need in our already too fragmented “system.” I know both Malinow and Tillow, and have the utmost respect for their experience and judgment.
There is no doubt that a uniform national program of Improved Medicare for All would be the best way to go, on the grounds of simplicity, efficiency, effectiveness and political sustainability. But so far I see no evidence that the Congress, as it is now constituted, has any appetite to enact anything close to Improved Medicare for All on a national scale anytime soon.
There are ongoing efforts in over twenty states to enact universal health care. Only one state, Vermont, has made a serious attempt to implement a universal health care system.
That attempt failed. Its failure was not due to economic, technical or statutory barriers, but almost entirely due to politics. Peter Shumlin, the Governor of Vermont at the time of the attempts to enact a universal health care system there, failed to adequately inoculate Vermont voters against the shock of transferring millions of dollars of private sector spending into taxes, as would have been required by full implementation of Green Mountain Care.
Shumlin, who barely won re-election for a second term, consequently throwing his re-election into the legislature, lost his nerve in the face of the prospects of the need to ask the legislature, that was poised to vote on his own election—for a substantial tax increase to fund Green Mountain Care despite the likely savings in overall health care spending that would have resulted if the program had been implemented.
The aversion to taxes and the resultant large government that is baked into American culture, (dating back to colonial times; Thomas Paine labeled government “a necessary evil”) is a major impediment to enactment of a universal health care program in the United States. It is one that proponents of universal health care, whether in the form of a state-wide or a national program, to overcome.
We have to persuade not only the public, but also legislators, that enacting a huge tax increase to fund health care is a good idea. I believe that as our health care system becomes increasingly dysfunctional—and increasingly expensive, voters will become increasingly willing to accept that reality. We UHC advocates must become much more effective at making the case that taxes, not private premiums and out-of-pocket payments, are the only just, merciful, and fair way to fund health care. They are likely the only way to achieve universal coverage. The U.S. is the last of the wealthy democracies to accept this reality.
We must also be more effective about explaining the virtues of everybody being in the same program (one size does fit all), and of a simpler, more transparent health care system with public accountability and the ability to control overall system-wide costs in a less intrusive way than the current system. As the current pandemic has demonstrated, we must also have a system that encourages policy-based investments in public health, whether in a national or state-based system—that only public funding can achieve. If there is any silver-lining in the Covid-19 pandemic, it is that has exposed the need for more investment in public health, which is undeniably a public good.
We must continue our intense focus on defending against the lies we know are coming from the opponents of major systemic changes even as we continue our campaign to win over the public for the idea of a publicly funded, universal health care system.
But at the same time, we must go on offense by focusing more on the benefits of such a systemic change for the vast majority of Americans. We all agree that a universal, federally funded and managed health care system is the best way to making health care as a right a reality in the U.S.
This is a classic example of the perfect being the enemy of the good. The paramount question is not whether we can achieve that perfect result, but how to get there from here, given the clash of interests in our current dysfunctional health care system.
Unfortunately, the current power of the medical-industrial complex in Congress is such that federal legislators must pay “tribute” to the the large health care corporations (just like the Mafia) that increasingly control the American health care system. The ACA is the prime example of one of the outcomes of this reality.
As an advocate for the past ten years of a state-wide program of publicly funded privately delivered universal health care in Maine, I can attest to the power of that idea to the public, if they believe it is achievable.
In reaction to the suggestion of a national solution to the problems of our health care system, people often roll their eyes. They don’t believe it’s achievable, because they don’t believe they have the power to overcome the political barriers that prevent that outcome. But when they hear about the possibility of a state-level solution, they pay attention and become activists in trying to make it happen—because they believe they may make a difference at a state level.
Just last month, over 70 Maine voters turned out to testify at a legislative hearing in support of universal health care bills that have been submitted to the legislature this session. The committee of jurisdiction of one of the bills (Maine LD 1045), not quite ready to vote to pass the bill due to concern that the state would lose some of its federal health care funds, carried the bill forward (didn’t kill it), and agreed to support it in the future on the condition that Ro Khanna’s State Based Universal Health Care bill (H.R. 5010), or something like it, was passed by Congress. They plan to introduce a joint-resolution to the full legislature later this year, asking Maine’s Congressional Delegation to support Representative Khanna’s bill.
That likely would not have happened if Maine AllCare, the state-level universal health care advocacy group I helped establish in 2010, had not been conducting educational programs for the public explaining the benefits of universal health care and organizing for support of a state-based plan. In addition, we developed the language of, and are advocating for the passage of, a Resolve that we hope to put on the 2022 ballot expressing public support for a publicly funded, privately delivered universal health care plan in Maine.
We believe such a program would not only be a step towards towards Medicare for All, but may be the only way to achieve such a program in the foreseeable future.
I share the concerns of Manilow and Tillow. I wish it was not so difficult to do the right thing in the U.S. I wish our country did not suffer from the systemic racism that has contributed so much to the difficulties they point out in their essay, and wish the American public had not been so susceptible to the anti-government propaganda from the right wing we have endured for the past 45 years. I wish we had not experienced the massive takeover of our health care system by profit-driven multi-national corporations. I wish the political class and some members of the Supreme Court didn’t think corporations are equivalent to people and money is equivalent to speech. But that is the reality we are living in, and we have to find a way around it.
The idea of state-level universal health care, despite its shortcomings, is a powerful and compelling tool for education and for organizing the power of the people that will be absolutely necessary to overcome the power of the medical-industrial complex.
People, at least here in Maine, respond differently to initiatives that are seen as local as opposed to national and near as opposed to distant, because they feel there’s a better chance they, as individual voters, can have a positive impact on the outcome.
Mobilizing the power of the people is the best shot we have to halt the destruction of our patient-focused health care system, and to preserve medicine as a self-regulating profession governed by the Hippocratic Oath, rather than the pursuit of maximum profitability,
We should continue to vigorously advocate for a universal publicly funded, privately delivered health care system at every level throughout America—state as well as national. That may be the only way to effectively reach and motivate enough of the American public to finally achieve our common goals as a nation—health care as a right for every resident of the U.S.—a goal that is already a reality in most wealthy, industrialized democratic societies, but remains only an aspirational vision in our own. Let’s use every tool at our disposal to turn that aspiration into a reality.
Dr. Philip Caper is a physician and founding member of the National Academy of Social Insurance and currently serves on the Board of Maine AllCare.
