California has thus far tried and failed. So has Vermont. So has Colorado. And Minnesotans are working on it.
But as of right now, the state closest to being the first to pass single-payer health care seems to be New York, whose lawmakers held a marathon 13-hour hearing in Albany, the capital, last week featuring speakers both for and against the New York Health Act. The bill would basically wipe out the private health-coverage industry in the state and replace it with a federal- and taxpayer-funded, state-run payer, leaving the provider side of health care in the state pretty much intact.
Bill supporters have touted the fact that, last year, a study from the nonpartisan RAND Corporation found that the bill was feasible and would save the state about 3.1% by 2031.
The New York Health Act, passed by the Democrat-controlled Assembly for the latest of several years in a row and only a few folks shy of gaining majority sponsorship in the state's newly Dem-controlled Senate, would cover absolutely everyone in the state, undocumented immigrants included, and in many ways would be more expansive than the state's current Medicaid and Medicare. It would cover things like vision, dental, and (crucially and expensively) long-term (elder) care -- which, critics note, was not factored into the RAND study.
The plan would have absolutely no premiums, deductibles, copays, or cost-sharing and would be funded by pre-existing federal money for Medicare and Medicaid, by a tax on employers of 8% to 10% of salaries (with a small percent of that picked up by workers) -- and by an investment tax on very wealthy New Yorkers (of which there are many).
Self-employed New Yorkers would pay about 10% of their income for the plan, and New Yorkers making under $25,000 would pay nothing. Those rates are similar to what self-employed and low-income New Yorkers pay now under Obamacare/Medicaid, but there would be no anxiety about choosing a plan based on which plans covered what and at what cost, since everything would be fully covered all the time.
And that includes meds. "There would be one drug formulary for 20 million people, and manufacturers would negotiate directly with the state over prices versus with several health plans, so [the drugmakers] must be terrified," said Mark Hannay, of the advocacy group Health Care for All New York, who was at the hearing.
A Very, Very Long Day
The well-attended hearing, convened by the health committees of both the state Assembly and Senate, started in the morning and, with only short breaks throughout, went until nearly midnight. "Many legislators stayed all the way through," stepping out only for quick bathroom or sandwich breaks, said Hannay. "They know this is a hot political issue with lots of public support."
On the "pro" side of the bill, highlights included Mitchell Katz, M.D., president and CEO of New York City Health + Hospitals, the city's vast public health and hospital system, who said that single-payer would fully cover the state's remaining uninsured or underinsured individuals, such as those for whom Medicaid is "generally accepted at hospital clinics, but not necessarily in the faculty practices of the same hospitals." A family with a disabled child spoke about the need for truly comprehensive coverage with no unexpected money traps for patients. And a speaker from the New York Immigration Coalition said that achieving single-payer is a social and racial justice issue, especially for undocumented immigrants. (The plan would welcome anyone who could show they had established residency in the state for 90 days or more.)
Speakers on the "con" side included reps from different groups in the Realities of Single Payer Coalition, whose website warns that single-payer would bring "Staggering Tax Increases -- Unprecedented Job Losses -- Government Run Healthcare." Those in the coalition are largely businesses and trade/commerce groups but also include some unions, which tend to already offer excellent health care coverage, such as the Civil Service Employees Association and the New York State Public Employee Conference. (However, other powerful unions, such as SEIU 1199 and the New York State Nurses Association, are vocal supporters of the bill.)
Some people planning to speak against the bill could not hold out until their late-evening slots and left. The hearing "went as well as could have been expected," given that it was organized by bill sponsors, said Leanne Politi, communications head for the Realities of Single Payer Coalition. "There was a good amount of balance, and we were glad to have as many members testify as we did."
On the other side, Katie Robbins, who heads the Campaign for New York Health, the coalition pushing the bill, called the hearing "a marathon ... definitely my first 13-hour hearing," and said it was "exciting to see so many people ask to testify, with most of them wanting to speak in support of [the bill]."
She cited a survey of 2,400 New Yorkers conducted by her group that found that half of them with private insurance delayed various forms of basic care -- dental, vision, diagnostic, and primary visits -- because they couldn't afford their share of the costs. Women, people of color, and transgender people experienced the most challenges in this regard.
"We have to not just cover everyone, but reform the current gatekeeping model," she said. "Having one high-quality care system can challenge systemic racism and stigma, because everyone's showing up with the same health care card regardless of immigration status or sexual or gender orientation."
So What Happens Now?
The bill still faces some serious hurdles -- among them, the likely need to build in concessions for unions to get them on board. There is also the matter of the many people in the state -- Politi estimated 60,000 -- who would lose jobs in the insurance industry, as the role for private health coverage would likely be limited to such things as cosmetic surgery. Robbins said that the bill ensures that laid-off workers in the field would receive unemployment compensation and would be prioritized for retraining to work in the new health system.
The bill also has to add at least one sponsor in the Senate. Supporters are looking to Democrats James Skoufis, who supported the bill when he was in the Assembly, and Diane Savino, who has said she has concerns about how the bill would affect unions.
With legislative support locked up, that would then be the time for a full-court press on Governor Andrew Cuomo. "If he's facing both an Assembly and Senate that's fully committed, he's going to have to then engage with the bill to shape it in a way that would be acceptable to him, such as a compromise here and there for the unions," said Hannay.
Then, of course, there is the Trump administration, which has already signaled that it will reject any waivers from states to transfer their (significant) federal funds for Medicare and Medicaid to single-player plans. Bill advocates hope that a Democratic administration will be in place by the time the bill is passed. But if it isn't, said Robbins, then New Yorkers covered by Medicare and/or Medicaid could enroll in single payer as "wrap-around" coverage for things those plans don't cover, such as vision, dental, and long-term care.
The biggest obstacle, of course, may be the behemoth private insurance industry, which is capable of pouring far more money into anti-single-payer ads and campaigns as the bill inches closer to a reality. And it may be helped by the broader Wall Street community, said Politi. "Wall Street provides 18% of the tax base [in the state] and there's the fear that taxing them at a higher rate will make firms say, 'We can operate out of New Jersey or Connecticut instead.'"
For now, lawmakers have said that they plan to do shorter versions of the hearings throughout the state, as many lawmakers and other stakeholders from far upstate were not able to get to Albany last week.
"They're taking the show on the road," said Robbins. And it's definitely a show worth watching, because if the bill ultimately becomes law, then New York's roughly two-year phase-in on the plan will be closely scrutinized by other states, much as Massachusetts' implementation of an Obamacare-like private-plan-driven universal health care system in 2006 attracted national attention and served as the model for Obamacare.
"Nobody is expecting the bill to move to the floor this year," said Hannay, "but we want another strong majority vote in the Assembly before the end of the session that says to the Senate, 'You need to take this seriously when you come back in January.'"