A Road Map to State Single Payer

This year, some of our movement’s most inspirational organizing has focused on state-level single-payer healthcare legislation. Consequently, our ally Public Citizen released a report today titled “A Road Map to ‘Single Payer:’ How States Can Escape the Clutches of the Private Health Insurance System.” The report aims to help state legislators and activists navigate the legal and legislative hurdles facing state-level single-payer efforts.

If you are active in a state single-payer campaign, we encourage you to download the report (.pdf) and share it with allies in your legislature.

Inspired by Vermont’s law designed to move the state through a series of phases culminating in a single-payer system, many other states have impressed us this year. Oregon activists organized a 1,000-person rally that resulted in passing a bill that compares the costs of single-payer with other healthcare financing systems. New York activists delivered over 10,000 signatures for single payer to legislators that resulted in securing a majority of the state Assembly supporting their state single-payer bill. Colorado activists launched a statewide ballot initiative to make access to healthcare a constitutional right, and is in the process of collecting 100,000 signatures.

Many states, however, do not enjoy the luxury of a state legislature that offers hope for single-payer legislation. We hope state-level victories will inspire national activism for achieving a right to healthcare for all, regardless of geography, income, or other social identities.

We hope that this Road Map will serve as a helpful tool in states’ organizing toolbox, and that you will share it with your network.


  1. Kay Tillow on July 17, 2013 at 8:49 pm

    By Don McCanne, M.D.


    This very useful Public Citizen report on steps toward single payer at the state level serves two important functions:

    1) Although the Affordable Care Act is providing a few beneficial tweaks to the financing of our health care system, by now it is obvious that, by building on our dysfunctional, fragmented system, intolerable health care injustices will be perpetuated. Yet Congress itself is currently so dysfunctional that it is impossible to get them to consider a vastly superior alternative – a single payer Improved Medicare for All.

    For those who cannot wait until we are able to elect a sane supermajority in Congress, this report provides suggestions on how some single payer principles could be applied at the state level. Although that pathway is rugged and cannot lead all the way to single payer, at least it would provide more improvement than we are seeing with the Affordable Care Act. There is plenty in this report to keep health justice activists very busy on the state level.

    2) The far more important conclusion to be drawn from this report is that states acting alone cannot establish a bona fide single payer system. There are too many major barriers that would prevent states from totally replacing their fragmented financing infrastructure. Under current federal laws, limitations imposed on states would not allow them to capture many of the more effective benefits of the single payer model.

    Although states could come much closer to universal coverage, their systems would still perpetuate many of the inefficiencies and inequities that exist today. Without the power of a public, single payer monopsony (a single buyer), improving allocation of our resources would be much more difficult. Although states could improve billing functions, that captures only a very small portion of the profound administrative waste in our system. Any savings on a state level would be very modest and would not be enough to pay for the elimination of uninsurance and underinsurance. Total health care costs would increase even more, when costs are already intolerable.

    The lesson? We cannot let up in the least in our efforts to educate the nation on the imperative of a single payer national health program. To be unequivocally clear, that’s NATIONAL.

    We cannot use the example of Saskatchewan and pretend that a state can set up a single payer system that could serve as an example for the nation – a model that could be expanded to all states. No. Saskatchewan began with a tabula rasa. They were able to create a de novo single payer system. The Public Citizen report shows us that our existing federal laws create complexities that would prevent states from enacting a financing model that could be held up to the rest of the nation as an example of the benefits of single payer, even though that is a noble intent of the report. In fact, there is a risk that such an effort would allow opponents to claim, “See, single payer doesn’t work.”

    Vermont is currently implementing legislation that originally was intended to bring it a single payer financing system. But they found that a bona fide single payer system is not possible, so they have abandoned the term, “single payer.” That might be wise advice for other state activists.

    We cannot allow enthusiasm for state efforts to diminish in the least the exhaustive effort that will be required to reach the threshold of political feasibility that will be a requisite to motivate Congress to take action.

  2. ポロ バック on November 2, 2013 at 7:17 am

    ラルフ ベビー

  3. C.S. on April 30, 2014 at 11:09 pm

    There’s an important problem which is going to stop state single payer efforts cold, and its the very narrow exceptions to the WTO GATS mandate to privatize. Basically, the US signed an agreement in the 90s agreeing to privatize our then existing public services gradually. The exceptions to this mandate are very narrow. One of the only ones is services provided as an exercise of governmental authority. However, some healthcare and education systems can remain public if they are completely free, no money is allowed and they do not “unfairly compete” in that market segment with any commercial activity or entity.

    Here is the text Article I:3 of the agreement states:

    “For the purposes of this Agreement

    (b) ‘services’ includes any service in any sector except services supplied in the exercise of governmental authority;

    (c) ‘a service supplied in the exercise of governmental authority’ means any service which is supplied neither on a commercial basis, nor in competition with one or more service suppliers.”

    The article “GATS and Public Service Systems” has a good discussion of the broadness of this really horrible “free trade agreement”