“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:

STATE-LEVEL ATTEMPTS AT “SINGLE-PAYER” HEALTHCARE ARE DOOMED NOT ONLY TO FAIL BUT TO SET BACK NATIONAL SINGLE-PAYER INDEFINITELY WHEN THEY INEVITABLY DO.

— crow­cial­ist ? (@McKChuck) March 12, 2018

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.