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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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