Why Don’t Any U.S. States Have Single-Payer Healthcare?

Photo by Pete Bobb | Photoshopped by Author

Depending on the poll question and sample size, single-payer has received on average about 30% — 60% U.S. support…

  • Kaiser Family Foundation (5/13–5/18): 57% favor

  • Business Insider (3/13–3/14): 49% favor

  • Quinnipiac (11/21–11/25): 36% favor

  • The Economist/YouGov (9/14–9/17): 45% favor

  • CBS News (8/28–9/4): 57% favor

  • RealClearOpinion (4/30–5/5): 55% favor

And according to the Washington Post, a majority of House Democrats now support Medicare for All.

No matter how we slice it there’s a sizable chunk of the American electorate, especially among Democrats, who support single-payer healthcare.

And so if this policy is so popular among Democrats then why hasn’t it been implemented by at least one Democrat-majority state, such as California, New York, Massachusetts, or Vermont?

For one, the problem with state-based single-payer healthcare is the federal government already plays a major role in providing and regulating the industry. About 17% of Americans are on Medicare, which is a federal health insurance program, but a state can work around that by filling the gap, i.e. people under 65 who aren’t disabled would be put into the state-based version.

We also know a state-based single-payer can be done because it had already been signed into law!

In 2011, Vermont signed into law the first state-based single-payer healthcare system.

The signing of H. 202 led to the creation of Green Mountain Care, which was described by Kaiser Health News as “a state-funded-and-managed insurance pool that would provide near-universal coverage to residents with the expectation that it would reduce health care spending.” Vermont Governor Shumlin described the plan as “a single-payer system” that he believed “will control health care costs, not just by cutting fees to doctors and hospitals, but by fundamentally changing the state’s health care system.” Vermont Representative Larson described Green Mountain Care’s provisions as “as close as we can get [to single-payer] at the state level.”

But in 2014 with all the roadwork laid, the governor saw what was up ahead and decided to turn back…

Calling it the biggest disappointment of his career, Gov. Peter Shumlin said Wednesday he was abandoning plans to make Vermont the first state in the country with a universal, publicly funded health care system.

“Going forward with a project four years in the making would require tax increases too big for the state to absorb,” Shumlin said. The measure had been the centerpiece of the Democratic governor’s agenda and was watched and rooted for by single-payer health care supporters around the country. Star Tribune

According to Shumlin, the plan would have required an additional 11.5% payroll tax and a 9.5% income tax increase. Shumlin was particularly concerned about Vermont’s small businesses going bankrupt.

In addition to economics, it’s also understandable from a political perspective why governor Shumlin threw in the surgical mask because, despite the fact Vermont consistently ranks in the top 10 most Democratic states, Shumlin almost lost reelection to a Republican mainly on the basis of his support for single-payer in what turned out to be the closest gubernatorial election in modern Vermont history with Shumlin getting 46.4% to Milne’s 45.1%. Governor Shumlin abandoned single-payer a month later.

Other states have also come close to single-payer.

California passed “The California Universal Healthcare Act” in 2006 and in 2008. Both times, Governor Arnold Schwarzenegger vetoed the bill (or should I say terminated). In 2019, Governor Gavin Newsom appointed a commission to study the feasibility of adopting a single-payer system in the state.

Colorado through a citizen-initiated constitutional amendment proposal put a state-based single-payer proposal directly on the ballot, but it was rejected by 79% of voters.

Hawaii got close to a state-based single-payer healthcare system. In 2009, its legislature passed a single-payer bill, which was vetoed by Republican Governor Linda Lingle. Lawmakers overrode the veto, but Lindle refused to appoint members or release funds. She was succeeded by a Democrat who then appointed members, but ultimately decided to abandon single-payer when talks turned toward ending private insurance.

The New York State Assembly passed a state-based single-payer health plan four times: 1992, 2015, 2016, and 2017, but it has never advanced through the New York State Senate.

Ultimately, state-based single-payer hasn’t been implemented because voters haven’t been enthusiastic enough about it, the business community adamantly opposes it, and politicians are risk-averse so when Democrats don’t have the power to implement it they are more likely to vote for it to placate their base, i.e. U.S. House of Representatives, California, Hawaii, New York, but then when they finally do have the power to implement it, .i.e. California, Hawaii, New York they don’t even put it up for a vote.

For example, as soon as Democrats took the New York State Senate in 2018, The Nation wrote,

A number of new or re-elected state senators, faced with the fresh possibility that single-payer might actually become a reality, have walked back their formerly full-throated support.

Much like Governor Newsom, Governor Cuomo has proposed a commission to look into it, but perhaps someone should have looked into it there before it was passed in the California State Assembly with broad Democrat support in the previous four legislative sessions?

Many Democratic politicians want to be seen as progressive fighters by doing everything up until implementation, i.e. passing a bill out of committee or chamber, forming a commission to look into it, and apparently even signing it into law, but then when it requires some unpopular moves such as eliminating private insurance or raising taxes they have thus far always backed down because they’re afraid of a repeat of what they saw in 2010 when Democrats lost power after the passage of Obamacare.

Overall, dark blue states’ inability to implement single-payer should give Medicare-for-All’s supporters pause because, for example, if such a homogenous, Democratic, and small state as Vermont can’t implement a functional single-payer system then what hope is there for the much larger and more ideologically divided federal government to do so efficiently? As Scott Adams said, “Ideas are worthless, execution is everything.”

Since Vermont’s near-miss at single-payer, the country has become much more polarized on the issue where Republicans support it less and Democrats support it more. The silver lining to this polarization is maybe Democrats and Republicans could agree to let the other be. You do you!

And then if single-payer health insurance does as its supporters contend, i.e. lower costs and increase quality, in states like Vermont, New York, and California then other states would choose to follow suit. Over time, this enthusiasm could spill over into a louder, bipartisan demand for a national single-payer system, but then at that point, many Americans may prefer to “keep their state plan.”