Will the Wyden/Brown state waiver enable single payer?

By Don McCanne MD for PNHP

The initial reaction to S. 3958, The Empowering States to Innovate Act, sponsored by Sen. Ron Wyden (D-OR) and Sen. Scott Brown (R-MA), is that the bill will enable states to bypass the requirements of the Patient Protection and Affordable Care Act (PPACA) and set up their own state-based programs, even single payer should the states prefer. But what does the bill actually say?

PPACA already authorizes a program for state waivers, but not until 2017. The Wyden/Brown bill does only one thing. It moves the state waiver program forward to 2014, the same year that the individual mandate and insurance exchanges go into effect. It does not change the waiver in any other way.

For those states that wish to establish their own programs, advancing the eligibility date removes the very burdensome task of complying with the insurance exchanges, mandates and other requirements for an interval of only three years, and then facing the additional costs and burdens of transitioning to their own programs. If you agree with the policy that states should be able to set up their own programs, then this is a very wise move.

Massachusetts already has a program similar to PPACA. Sen. Brown would much rather modify what they have by complying with the waiver than to have to comply with all details of PPACA for the first three years. For Sen. Wyden, his preferred model of reform was rejected by Congress, but he would still like to experiment with his model, as much as possible, within the state of Oregon, while protecting what innovative programs they already have.

So just how much leeway does the PPACA state waiver allow? It does allow innovations as long as coverage is at least as comprehensive, cost sharing is at least as affordable, at least as many residents would be covered, and as long as the federal deficit would not be increased. It also passes through to the state the funds that would have been used for premium tax credits, cost-sharing reductions, and small business credits. Is that enough funding to establish a single payer system?

What about the funds for Medicare? Medicaid? CHIP? Taft-Hartley plans? What about ERISA requirements? What about the multitude of other funding requirements such as the VA system, academic institutions, safety-net institutions, community health centers, the Indian Health Service, the U.S. Public Health Service, and the many others?

There is no authorization in the Wyden/Brown bill, PPACA, nor any other existing law or regulation to fold many or all of these programs into one single payer system. Think of trying to run a partial single payer system (an oxymoron) while still having to deal with the massive Medicare and Medicaid programs. The point is, don’t let up on your advocacy, thinking that Wyden/Brown is our entry to single payer. We would still have a highly fragmented financing system.

Our best option remains enacting a national single payer bill such as HR 676, which will be re-introduced in the next session of Congress. In lieu of that, we should continue with our efforts to enact single payer systems on the state level. Just don’t be fooled into thinking that a bill such as Wyden/Brown is the ticket. The enabling federal legislation that would be required for state programs would be as complicated, if not more so, than a bill establishing a national single payer program – an improved Medicare for everyone.

Vermont is a test. Without enabling comprehensive federal legislation, I’m already apprehensive.


  1. Carolyn Taylor on December 7, 2010 at 12:35 pm

    Why are we ruling out HB676? It will save the country SO MUCH MONEY! We already have the most expensive health care cost per person in the world, partly BECAUSE so many of our people are not covered. We end up paying for them, though, using the most expensive type of care–emergency room treatment–long after cheaper, preventive or office care could have avoided the emergency room visit. Why are we 38th in the world when it comes to health care? It’s because we believe the bloody conservative talk radio hosts and the politicians who have been PAID OFF by the greedy insurance companies who won’t give up their cash cow, won’t take their hands out of the cookie jar. When will America WISE UP???!!!

    • Carrie Noah-Short on December 7, 2010 at 1:22 pm

      That is the truth in a nut shell. The insurance companies are via the lobbyist brainwashing the American people. There is so much money at stake that if they were put out of business we would have plenty to go around for healthcare and the efficiency would add to the savings. We have to keep up the cause, the faith, and we will win our fight for a one-payer system. God bless all of us who fight for healthcare reform! I am so passionate about reform I would give my life to work towards our goals.
      Carrie Noah-Short, BA Healthcare Management
      working towards Masters in Healhtcare Adminsitration

    • HC-N! on December 7, 2010 at 5:41 pm

      Carolyn, Healthcare NOW! is still fully behind HR 676 as the only solution to our health crisis. However, passing single-payer on the state level may be an important strategy to win single-payer nationally. We are using all the resources we have to keep fighting for HR 676. Thanks for your support!