Single Payer Rises Again

As the ACA takes effect, an alternative gains ground at the state level.

By Sarah Jaffe for In These Times

When Sergio Espana first began talking to people, just over a year ago, about the need for fundamental changes in the U.S. healthcare system, confusion often ensued. Some people didn’t understand why, if the Affordable Care Act (ACA) had passed, people still wanted to reform the system; others thought organizers were trying to sign them up for “Obamacare.”

Healthcare is a Human Right Maryland, the group to which Espana belongs, is in pursuit of something else: a truly universal healthcare system that would cover everyone and eliminate insurance companies once and for all. Espana and many others in the growing movement see opportunity in the renewed discussion around healthcare reform as the ACA’s insurance exchanges go into effect.

They believe that the ACA’s continued reliance on (and subsidies of) private insurance simply aren’t good enough. People are still falling through the cracks, employers are trying to dodge the requirement that they provide insurance for their workers, and many states refused federal subsidies to expand their Medicaid programs. What these activists want is a program that would replace existing insurance programs, cover everyone regardless of their employment status, and be funded by the government, with tax dollars. Such a plan had strong support when the national healthcare overhaul was being crafted in 2009—including initial backing by President Obama—but the president and Congress decided it wasn’t politically possible and passed the ACA as a compromise.

Now, the rocky launch of the healthcare exchanges that form the cornerstone of the Affordable Care Act has helped revive interest in single-payer, says Ida Hellander, director of policy and programs for the advocacy group Physicians for a National Health Program. New York State Assemblymember Richard Gottfried, the author of a 20-year-old single-payer bill that is receiving renewed support, points out that single-payer would avoid many of the issues of the ACA’s launch. “When you don’t have means testing and you don’t have to make guesses about who’s going to cover your doctor or your ailment, it’s very simple.”

While Republicans on the national stage have been grandstanding about “repealing and replacing” the ACA, grassroots activists are on the ground in many states organizing their neighbors around the idea of real universal healthcare. A national program remains the end goal, but Nijmie Dzurinko of Put People First! Pennsylvania believes that state efforts could have a domino effect. “Our job is to change what’s politically possible,” says Drew Christopher Joy of the Southern Maine Workers’ Center, which is leading the effort in that state.

According to Hellander, about 25 states already have solid organizing toward single-payer, often accompanied by pending legislation. Some of these efforts predate the ACA: The California Nurses Association led the charge for single-payer in the mid-2000s, twice getting a bill through the California legislature only to have it vetoed by Gov. Arnold Schwarzenegger. Hellander says that the ACA has slowed down some efforts at state reform, as officials turned to setting up exchanges, but the law spurred others in Minnesota, Washington, Hawaii and Oregon. In New York, Gottfried notes that his bill has support from physicians groups, the nurses union and a majority of the lower house of the legislature. And in Massachusetts, considered the laboratory for the ACA, single-payer is now on the table thanks to gubernatorial candidate Don Berwick, the former administrator of the Centers for Medicare and Medicaid Services under Obama.

The biggest legislative victory to date has come in Vermont. Act 48, signed into law by Gov. Peter Shumlin in May of 2011, would begin to create a “universal and unified” healthcare system for the state. The bill, pioneered by the Vermont Workers’ Center (VWC), is at the cutting edge of national healthcare policy. Its passage resulted from years of on-the-ground organizing around the principle that healthcare is a human right—that it must be universal, equitable, participatory, transparent and accountable.

However, Act 48 marks just the beginning of a lengthy process toward healthcare for all residents of the state, regardless of employment or citizenship. The next steps are to figure out how “Green Mountain Care” will fit into federal requirements set by the ACA and to pass a mechanism by which the program will be financed.

The VWC favors a more progressive income tax on individuals and employers, along with a wealth tax. Mary Gerisch, president of the VWC, says, “Even though new taxes or progressive taxation sounds very scary, in reality it’s going to be cheaper for everybody, just like it is in every other country, for them to pay it in taxation rather than to pay out of pocket at the doctor.”

This growing movement has attracted growing opposition, says Gerisch, who notes that a number of TV ads and websites have popped up to oppose Green Mountain Care. And Vermonters for Health Care Freedom, a new 501(c)4 organization founded by longtime Republican political operative Darcie Johnston, has paid for several ads and robocalling campaigns against the plan.

Small business owners, in particular, are susceptible to the fear that new taxes will put them out of business, Gerisch says. She mentions one example of a small business owner who was worried about a 10 percent tax (even though no tax has been decided upon), only to find out that he was already paying 13 percent of his profits to buy insurance for his employees, which would be unnecessary under a state plan.

Healthcare is a Human Right believes the organizing model pioneered in Vermont represents the best chance for passing universal healthcare, and the group is forging ahead with that model in its Maine, Maryland, and Pennsylvania chapters. Among the key elements are base-building and education. To combat corporate scare tactics, activists focus on arming citizens with good information.

In Maryland, according to Espana, more than 90 percent of the 1,200-plus people the organization has surveyed over the last year believe that healthcare is a right, and more than 86 percent support a publicly funded system. “Maryland has been coming off more and more as a progressive state. We’ve been able to get some version of a DREAM Act through, we got marriage equality last year—those are great victories but, economically, they’re not that transformational,” he says.

Joy sees an opportunity to build a strong community-labor alliance around universal care in Maine, where the state AFL-CIO has gotten on board with the Healthcare is a Human Right campaign, and the Maine State Nurses Association held a free health clinic to provide services and connect people to the campaign.

Dzurinko and Put People First! Pennsylvania have been organizing statewide—not only in Philadelphia and Pittsburgh, but in rural counties where the conventional wisdom has been that progressives can’t win. Dzurinko says that people in those counties frequently suggest, unprompted, that the U.S. should have a national healthcare system “like in Canada.”

“We often limit ourselves tremendously by not talking to people that we fear or that we have been told won’t agree,” Dzurinko says. “We can’t talk about universality unless we really are talking about everyone, and that means organizing in all communities.” Joy agrees: “If you’re not taking the time to really organize from the ground up, we’ll end up with the ACA again.”

For Espana, organizing around single-payer presents an opportunity to begin a broader discussion about economic justice and human rights. “All of these politics of austerity are just lies,” he says. “Through a fight for healthcare reform you can demonstrate that not only is it morally righteous for us to have a universal healthcare system, but it’s actually cheaper.”


  1. David Greenstein OD MS on February 12, 2014 at 1:39 pm

    I could not agree more. The present ACA continues the most inefficient system of paying for health care in the world. The 1300 health insurance companies wrote the law and bribed congress one million dollars a day to get what they wanted and they succeeded. Government of the people by the people and for the people sadly failed. The president and congress did not even discuss the idea of extending Medicare all our citizens (for”political” reasons). They all caved in to the wishes of the insurance companies. We need brave and courageous leaders who are not afraid to do the right thing instead of what is most politically expedient.

  2. Thomas Cox PhD RN on February 12, 2014 at 2:18 pm

    The issue is not just getting a single payer – but how the single payer manages its insurance risks. At present Medicare manages much of its insurance risk by transferring it to hospitals, physicians, nursing homes, home health agencies and allied health care providers.

    These insurance risk assuming health care providers become their patient’s tiny, extraordinarily inefficient health insurers. Remove this inefficiency and Medicare for all could be the most mathematically and financially efficient insurer possible, achieving universal coverage at the lowest possible price in the aggregate.

    Consider this – many people think that the optimal size for a physician practice is about 2,000 patients. A generous capitation system might provide annual payments of $6,000/patient. A physician would have to manage gross revenues of $12,000,000 and care for all their patients. If the physician spend $12,000,000 before December 31 the care needed for the balance of the year is unfunded. More to the point, it would take 157,500 primary care physicians to do this and half of them would have higher than expected costs and earn less than they expected to earn. A few would have costs above $20,000,000 – $30,000,000 through no fault of their own – their patients just happen to be sicker than average.

    At the same time, a few would have costs of $5,000,000 – $10,000,000 earning outrageously high profits through no virtue of their own – – their patients just happen to be healthier than average.

  3. Charles Semler on February 12, 2014 at 2:27 pm

    I live in the state of Md, and all I have heard , is the ACA, is not affordable ,plus high deductibles. My daughter and son in law and two children have been without health insurance for at least six years,after losing a job with health benefits. They both have pre-existing issues and were only able to find two insurers that would insure them , but the costs were prohibitive. They hoped they would be able to get affordable health care after the ACA took effect. But all they found was insurance that was too expensive for them, so they have elected to pay the penalty. How is it that affordable health coverage is unaffordable? I would like to know the truth. We read where people in other states with high incomes are paying very low premiums with great coverage.
    I think we need a government run health plan , with no insurance companies involved.Something on the order of Medicare where everything is covered without the need for a supplemental insurance from an insurance co.It should be able to operate at a whole lot less expense and much better coverage.
    We have got to get away from health care for profit. Health care should be all about health care.

    • NEIL STECKER on February 12, 2014 at 9:09 pm

      Charles Semier, (and others) stated it just about perfect. Until the insurance companies are out of profit mode, (business) your life could be worthless. Worse, you may have to live or DIE, with what the industry sold you. Like the “you can keep your (lousy) policy,” republicans whores sold TO US, now claim what a FAILURE AMA IS, because it’s OBAMA-CARE. MEDICARE FOR ALL, END INSURANCE COMPANIES! It is too obvious to ignore!

      Listened to HATE TV FOX-NEWS, I could not believe how many dis-proven facts were being spouted as TRUTH and CURRENTLY ACCEPTED! BY WHO!!!

      I have spent 35 wasted years trying to keep my OPEN MEDICAL AWARD OPEN! KEMPER, BROADSPIRE, CRAWFORD, are my nemesis, withheld OPEN MEDICAL AWARD FOR 8.5 YEARS THIS TIME. Whenever I go back to CA, (a 4,000 miles trip, at My Own Expense,) the WCAB JUDGE REINSTATES OPEN MEDICAL. How many trips a year could you make???

      I would willingly abandon the care, but I will still have the pain. WHEN the PAIN stops is when I would not need the care! Permanent and Stationary as of 1980, Judge OBATA, Stockton, CA.
      Chiropractic on a PRN,(?) as needed, 2 to 6 times a month, measured by how hard I’ve worked, if any, and pain level.
      Journeyman union carpenter, 30% PPD = 60% disabled & 100% FUCKED BY KEMPER, ET EL.

      Thank you all, well put, everyone in, no one out, “but the INSURANCE COMPANIES!” SINGLE PAYER would eliminate WORKERS COMP AND THEIR LAWYERS!
      Where everybody but the injured, make their wages!

      I hope to never have to work with anyone from an insurance company again! They knowingly send you down dead ends, Kelly STALLCOP, AT CRAWFORD, gave me a number for a trip to the Bahamas, as her office number. Good to have caller ID. They must relish when they tighten the screws on you! Could they be SADISTS, CONTROL FREAKS, MALEVOLENT, or JUST SCUMBAGS???


      • NEIL STECKER on February 12, 2014 at 9:22 pm

        Kelly STALLCOP’s office number, 800-255-0185

        caller ID was 916-850-8178. Ask KELLY, how they have the BALLS to keep closing my AWARD, this time 8 1/2 +, years!

        Nothing short of returning to CA seems to work, MAYBE if you call them and ask. never know how many of you have had this too! I WILL CALL FOR YOU!?!

  4. Oolaa on February 12, 2014 at 2:43 pm

    I would love to see Single payer in my lifetime. After reading some of what’s in the detailed newsletter single payer rises again, I’m not seeing how you intend in MD my home state, ( currently live in Seattle) to reach the masses , those who still think sp is a dirty word and represents bad Canadian care or worse is ‘socialist’?

    speaking to people like me or those in the organization is speaknig to the choir.
    ehia person, family needs to be educated likely where they live. expecting people who don’t believe in this to come to talks, is not prudent. they likely won’t. it’s had enough to get people who do believe and work and have families to come to be educated.

    I think by far the most difficult challenge is reaching those Others with information that can address concretely their concerns & needs. Abstract information won’t do it for many. curious what others think.

  5. Edward on February 12, 2014 at 3:11 pm

    How about a single payer system where the goverment collects the money and makes up the rules and then bid out to the insurance industry then both will make out and no one will be gouged.

    • Thomas Cox PhD RN on February 12, 2014 at 4:37 pm

      Edward: What functions would the insurers perform and how much would we pay them to perform them? If the government is making rules that insurance companies can follow we can program a computer to follow the rules and once we program the computer it will work 24/7 with no profit margin. Can you think of any insurers that can compete with this computer?

  6. Donna on February 12, 2014 at 3:21 pm

    I think there may still be a lot of misunderstanding within the general population about what Single Payer actually is and how it is funded. Health care is a right; not a privilege. Government funded health care is like Medicare. Taxes taken out of paychecks is hardly noticeable by most people. I have Medicare/Medicaid. I am on a limited income plan for my medications. My medication co-pays are very reasonable. Neither Medicaid nor Medicare will cover hearing aids or glasses, though. I support Single Payer. A person would be covered from birth to death no matter what.

    • Thomas Cox PhD RN on February 12, 2014 at 4:46 pm

      Donna: It is nice to imagine that people can acquire the information they need to make critical decisions with no effort. But it is unrealistic. If you listen to FauxNews, CNN or MSNBC you pretty much get fed a lot of rubbish that assumes that a national health insurer cannot be as efficient as over 1,000 private, profit-seeking health insurers.

      This, of course, is utter hogwash. A single national health insurer will always be the most mathematically efficient insurer for any population.

      Part of the problem is that those who favor a national health insurer contribute to the problem, asserting, for example, that “Healthcare is a Human Right”. This is moot. Good people can disagree with whether health care is a human right, or not. What nobody can disagree with is that a single, insurance risk retaining national health insurer is the mathematically most efficient insurance risk manager possible.

      If those who support a single payer system aren’t championing the most significant virtue of a single payer how can we expect to win anyone over? It is like engaging in a duel blindfolded and with both hands tied behind your back.

  7. HOWARD C LUCAS, MD on February 12, 2014 at 5:41 pm