NPI's Cascadia Advocate

Offering commentary and analysis from Washington, Oregon, and Idaho, The Cascadia Advocate is the Northwest Progressive Institute's uplifting perspective on world, national, and local politics.

Tuesday, March 13th, 2018

Why states are a good place to fight for health care as a human right

“Courage, my friends; ’tis not too late to build a bet­ter world.” — Tom­my Douglas

In 1944, the Coop­er­a­tive Com­mon­wealth Fed­er­a­tion won the Saskatchewan gen­er­al elec­tion, bring­ing the first social demo­c­ra­t­ic gov­ern­ment to a state or province in North Amer­i­ca. The CCF’s leader and Saskatchewan’s new Pre­mier, Tom­my Dou­glas, began work­ing to imple­ment a uni­ver­sal, sin­gle-pay­er health­care sys­tem at the provin­cial level.

He did not wait for the Cana­di­an fed­er­al gov­ern­ment to do so. And his work to imple­ment sin­gle-pay­er in one province helped pave the way to Cana­da pro­vid­ing sin­gle-pay­er in all of its provinces and ter­ri­to­ries, backed by the fed­er­al Cana­da Health Act.

Saskatchewan’s lead­er­ship proved uni­ver­sal, sin­gle-pay­er health care was pos­si­ble and gen­er­at­ed momen­tum and pres­sure to adopt it federally.

While coun­ter­fac­tu­als are dif­fi­cult to assess, it’s unlike­ly that the Cana­di­an fed­er­al gov­ern­ment would have adopt­ed sin­gle-pay­er on its own with­out that suc­cess­ful pres­sure that began on the Saskatchewan prairie.

The lessons for the Unit­ed States are clear: the path to sin­gle-pay­er health care can, and per­haps will, begin in the states themselves.

This is not the only path, but as Cal­i­for­ni­a’s expe­ri­ence demon­strates, it’s a path that has already helped fuel a nation­al move­ment that could deliv­er a fed­er­al Medicare for All bill. There is no inher­ent rea­son to believe that a state effort for sin­gle-pay­er would clash with or under­mine a fed­er­al effort.

Unfor­tu­nate­ly, that’s the argu­ment being made by a few of my fel­low mem­bers of the Seat­tle branch of the Demo­c­ra­t­ic Social­ists of Amer­i­ca. Andrej Markovic, past chair of Seat­tle DSA, wrote a very good arti­cle address­ing short­com­ings with Ini­tia­tive 1600, a pro­pos­al to cre­ate a sin­gle-pay­er sys­tem here in Wash­ing­ton State.

I take no issue with the spe­cif­ic crit­i­cisms Markovic raised of I‑1600 itself, an ini­tia­tive which NPI has not tak­en any posi­tion on. But I must strong­ly dis­agree with his asser­tion that it is wrong to push for sin­gle-pay­er at the state lev­el, a view I was dis­tressed to hear voiced by sev­er­al folks at a Seat­tle DSA meet­ing back in January.

Here’s what Markovic said on the matter:

The fed­er­al gov­ern­ment can absorb these costs because, unlike our state gov­ern­ment, which has a bal­anced bud­get require­ment, the fed­er­al gov­ern­ment can effec­tive­ly deficit spend as much as it needs. Since it can print its own sov­er­eign cur­ren­cy, it is able to pump mon­ey into the econ­o­my dur­ing an eco­nom­ic recession.

Then we sim­ply remove the bal­anced bud­get and debt ceil­ing rules as part of a sin­gle-pay­er push. Those rules in the state con­sti­tu­tion are deeply regres­sive and will always stand in the way of Wash­ing­ton State ever adopt­ing any kind of uni­ver­sal ben­e­fit sys­tem, whether it is for health care, hous­ing, and so on.

Those rules pro­mote aus­ter­i­ty bud­get­ing dur­ing reces­sions and need to be elim­i­nat­ed regard­less of what hap­pens with single-payer.

How­ev­er, they won’t be elim­i­nat­ed by them­selves. Nobody mobi­lizes in sup­port of good gov­ern­ment mere­ly for the sake of good gov­ern­ment. But as we’ve seen in the past, rules like those can be swept aside as part of an effort to expand social pro­grams, such as a statewide sin­gle-pay­er sys­tem. If we build momen­tum for it in Wash­ing­ton State, that cre­ates the momen­tum to remove those and oth­er legal and con­sti­tu­tion­al obsta­cles stand­ing in the way of sin­gle-pay­er. We need to think big and be ambi­tious here.

In an eco­nom­ic down­turn, WA would be hit with a wave of peo­ple sign­ing up for this state plan. Since the state would no longer be direct­ly dis­burs­ing fed­er­al funds to health­care providers as before, but rather rely­ing on invest­ment income from the state health fund, the fund­ing for this state plan would be depen­dent on mar­ket con­di­tions. Ulti­mate­ly what you would see in a time of eco­nom­ic cri­sis is a rise in the pro­gram cost com­pound­ed by a drop in pro­gram fund­ing. This ties the pro­vi­sion of an essen­tial human right to the pre­car­i­ty of the pri­vate mar­kets, pre­cise­ly the mod­el from which we are try­ing to break free.

Markovic here is explain­ing why we need to elim­i­nate bal­anced bud­get­ing and debt ceil­ing rules from state con­sti­tu­tions — with­out doing so we will always be lashed to the pri­vate mar­ket, no mat­ter the issue or pol­i­cy goal. We can­not let those rules just stand in place and become excus­es for inac­tion. Cana­di­an provinces do not gen­er­al­ly have such require­ments, which are one rea­son why they can admin­is­ter and help fund their pub­lic health care sys­tems. But again, we will only sweep aside those rules as part of a broad­er mobi­liza­tion to win some­thing big — like single-payer.

It is addi­tion­al­ly worth not­ing that it is extreme­ly unlike­ly that any cost sav­ing mea­sures could be achieved through scale. The fed­er­al gov­ern­ment is still pro­hib­it­ed from nego­ti­at­ing over drug prices. If this plan antic­i­pates bundling togeth­er fed­er­al Medicare and Med­ic­aid funds into a sin­gle pro­gram, we shouldn’t expect phar­ma­ceu­ti­cal com­pa­nies to sim­ply roll over and allow us to bar­gain with them.

That’s true, but we can­not expect phar­ma­ceu­ti­cal com­pa­nies to ever roll over on any­thing. It will require orga­niz­ing and strug­gle, no mat­ter what path we choose to fol­low. I would add that the argu­ment that we would not real­ize sig­nif­i­cant cost sav­ings at scale is hard to accept. Wash­ing­ton State is home to more than 7 mil­lion peo­ple, which is a sig­nif­i­cant scale that enables the state to nego­ti­ate direct­ly with doc­tors, hos­pi­tals, and phar­ma­ceu­ti­cal com­pa­nies. They will push back, as they did in Saskatchewan, but a move­ment that can win leg­isla­tive or vot­er approval of sin­gle-pay­er is a move­ment that can stare down that kind of resistance.

Final­ly, I‑1600 assumes that the fed­er­al gov­ern­ment will sim­ply coop­er­ate. It asks them to give WA state all the mon­ey they have been pay­ing to var­i­ous health­care pro­grams and allow the state gov­ern­ment to deter­mine its own cri­te­ria for who would qual­i­fy instead of fol­low­ing fed­er­al guide­lines. Bar­ring any leg­isla­tive changes on the fed­er­al lev­el, expect­ing the fed­er­al gov­ern­ment to go along with this seems at min­i­mum incred­i­bly opti­mistic. But if we are expect­ing to be able to exert that much pres­sure on the fed­er­al gov­ern­ment, why com­pro­mise on our exist­ing and supe­ri­or goal of a nation­al sin­gle-pay­er system?

It’s not incred­i­bly opti­mistic at all. Under the Patient Pro­tec­tion Act there is a pro­vi­sion to award “State Inno­va­tion Waivers” that was designed by Ore­gon Sen­a­tor Ron Wyden to allow state-based sin­gle-pay­er plans. There are plans in the works from pro­gres­sive Democ­rats in Con­gress to pro­pose changes to the Employ­ee Retire­ment Income Secu­ri­ty Act of 1974 (ERISA), an act which cur­rent­ly pre­empts a lot of the state inno­va­tion need­ed for single-payer.

Democ­rats stand a good chance of retak­ing one or both cham­bers of Con­gress in 2018 and the White House in 2020.

While we would absolute­ly want to con­tin­ue push­ing for Medicare for All in Con­gress, changes to ERISA to enable state sin­gle-pay­er projects seems an easy win no mat­ter which can­di­date Democ­rats nom­i­nate in 2020. That all being said, the main objec­tion to state sin­gle-pay­er move­ments seems to be polit­i­cal, not practical.

This tweet from a DSA mem­ber is a good exam­ple of the basic argument:

This is an under­stand­able sen­ti­ment — and a evi­dence shows, it’s also wrong.

There are two state sin­gle-pay­er efforts that failed in recent years. Nei­ther fail­ure set back the nation­al move­ment at all.

Ear­li­er this decade, Ver­mont passed leg­is­la­tion cre­at­ing a state-based sin­gle-pay­er sys­tem. The only prob­lem, and it was a big one, was how to pay for it. The tax increas­es would be large, but they would also be much more afford­able than the cost to employ­ers and work­ers of pri­vate insur­ance pre­mi­ums, deductibles, copays, and so on. Big busi­ness­es did not want to bear those tax oblig­a­tions and instead want­ed work­ing peo­ple to do so.

Ver­mon­t’s Demo­c­ra­t­ic gov­er­nor, Peter Shum­lin, won re-elec­tion in 2014 by a much small­er mar­gin than he had expect­ed. Soon after that elec­tion, he shocked the state and sin­gle-pay­er sup­port­ers by announc­ing he was aban­don­ing the sin­gle-pay­er plan entirely.

Shum­lin was appar­ent­ly wor­ried that his busi­ness allies would aban­don him in his re-elec­tion bid if he pressed ahead with sig­nif­i­cant tax increas­es on them. (Iron­i­cal­ly, Shum­lin decid­ed to not run for re-elec­tion in 2016 any­way.) While this raised legit­i­mate ques­tions about sin­gle-pay­er in a state as small as Ver­mont, this expe­ri­ence has done noth­ing to slow the growth of Medicare for All activism across America.

Sim­i­lar­ly, the defeat by a wide mar­gin of Col­orado’s Amend­ment 69 in the 2016 elec­tion has not stopped the growth of state-based efforts. The ini­tia­tive was plagued by infight­ing among Demo­c­ra­t­ic and pro­gres­sive groups, includ­ing charges that it would lock in place anti-abor­tion rules in the state con­sti­tu­tion. Amend­ment 69 only won 21% sup­port from vot­ers — yet here again we can see clear­ly that this fail­ure has not set back the nation­al move­ment for Medicare for All.

In fact, we can look at Cal­i­for­nia to see how a state based sin­gle-pay­er effort can help build momen­tum for a nation­al Medicare for All plan.

A mass mobi­liza­tion helped get the sin­gle-pay­er bill through the Cal­i­for­nia State Sen­ate, and has fought back hard against efforts by cen­trist Democ­rats to block the bill in the Cal­i­for­nia State Assembly.

That effort has been pow­er­ful enough to grab the atten­tion of mem­bers of Con­gress, who often close­ly watch issues and mass move­ments back home.

It is no coin­ci­dence that the first Sen­a­tor to co-spon­sor Bernie Sanders’ Medicare for All bill in 2017 was Cal­i­for­ni­a’s Kamala Harris.

Cal­i­for­ni­a’s sin­gle-pay­er move­ment has also helped pro­pel Kevin de León, the State Sen­ate pres­i­dent who ush­ered the bill through that leg­isla­tive body, to mount a pow­er­ful chal­lenge to entrenched Demo­c­rat Dianne Fein­stein — mak­ing Medicare for All a cen­ter­piece of that all-impor­tant fed­er­al elec­tion campaign.

After all, it makes sense that if some­one is will­ing to take action for sin­gle-pay­er at the state lev­el, they’ll do so at the fed­er­al lev­el too. Some­one who is will­ing to car­ry a clip­board of I‑1600 peti­tions is also some­one very like­ly to want to mobi­lize peo­ple to lob­by Wash­ing­ton State’s Con­gres­sion­al del­e­ga­tion, which bad­ly needs lob­by­ing on Medicare for All. If you’re will­ing to vis­it a state leg­is­la­tor’s town hall and argue for sin­gle-pay­er, chances are you’ll do the same for a Con­gres­sion­al town hall too.

There are legit­i­mate pol­i­cy dis­cus­sions to be had about I‑1600 itself, as with the var­i­ous bills pro­posed in Olympia to cre­ate a state sin­gle-pay­er plan via leg­isla­tive action. Those are exact­ly the kinds of con­ver­sa­tions we all should be having.

It may also be the case that the path to Medicare for All in the Unit­ed States begins, as it did in Cana­da, at the sub-nation­al lev­el. Saskatchewan was a rur­al province with a pop­u­la­tion of less than a mil­lion when it made Medicare for All a reality.

Wash­ing­ton State is a lead­ing glob­al econ­o­my with more than sev­en mil­lion res­i­dents. And if we want­ed to com­bine forces with Ore­gon’s five mil­lion peo­ple and Cal­i­for­ni­a’s 40 mil­lion peo­ple, we would have an amaz­ing econ­o­my of scale that would make sin­gle-pay­er even eas­i­er. And, as in Cana­da, once we prove sin­gle-pay­er works, we could make it eas­i­er to make the leap federally.

Or we pass it fed­er­al­ly all at once. That is the ide­al path and one that is not fore­closed or harmed by also sup­port­ing good state-based efforts too.

But we miss a huge oppor­tu­ni­ty to mobi­lize the pub­lic around DSA as an orga­ni­za­tion and around the issues and val­ues it pri­or­i­tizes to sim­ply write off state-based sin­gle-pay­er efforts as inher­ent­ly unwinnable.

After all, NPI’s own polling shows that 64% of Wash­ing­ton vot­ers sup­port Medicare for All and 50% strong­ly sup­port it.

This is not only good news for the health care as a human right move­ment — it’s also a huge strate­gic oppor­tu­ni­ty for orga­ni­za­tions such as DSA to grow its membership.

Good left-wing orga­niz­ing involves tak­ing oppor­tu­ni­ties when they arise. It also involves not buy­ing into nar­ra­tives of pow­er­less­ness. The prac­ti­cal obsta­cles to sin­gle-pay­er at both the state and fed­er­al lev­els are real. They won’t be eas­i­ly swept aside. But they can be removed through mass orga­niz­ing for single-payer.

This is a moment tai­lor-made for DSA.

I hope DSA lead­ers will rec­og­nize it and embrace the oppor­tu­ni­ty to help build a state and a coun­try for the many, not the few.

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