How single-payer health insurance efforts have fared in some states

California may be the latest (and most consequential) state to take steps toward implementing a universal, or government-run, health insurance system that guarantees coverage for all residents—but it’s not the first.

Lawmakers across the US—from traditionally blue states like Vermont and New York to more conservative states like Ohio and Iowa—have introduced dozens of single-payer proposals with varying levels of success in the last 10+ years. That includes 66 unique proposals across 21 states between 2010 and 2019 alone, according to a 2020 University of Pennsylvania Law Review analysis.

Although most of those bills have been “political long shots in their state legislatures,” authors Erin Fuse Brown and Elizabeth McCuskey noted in the report, “collectively, they do not appear to be purely symbolic or precatory” given the level of detail in the bills.

The continued interest in universal health insurance suggests that the policy issue is not going anywhere.

So if California—a state with one of the world’s largest economies and a population larger than that of several countries, including Australia—can get universal health insurance right, that could have major implications for the rest of the US.

Vermont’s cautionary tale

Vermont became the first state to pass single-payer legislation in 2011. But in late 2014, then-Governor Peter Shumlin announced the state would not move forward to create the publicly financed health insurance system after an analysis suggested it would require an 11.5% payroll tax for employers and up to 9.5% income tax to finance. Vermont’s income tax rates ranged from 3.55%–8.95% in 2014.

Single-payer advocates have continued to push Vermont lawmakers to advance a publicly backed health system in the years following Shumlin’s decision—something he described as “the biggest failure of [his] political leadership” in a 2019 interview with local news source VTDigger.

Some Vermont lawmakers, however, remain concerned about the costs associated with a single-payer system, Vermont Public Radio reported in 2022.

They’re not the only ones who’ve raised concerns about the costs associated with establishing universal health insurance programs. Critics—including insurers and hospital groups—have questioned how large states like New York could successfully implement a single-payer system if similar efforts had failed in Vermont, which has a population of just 647,000 people.

New York’s single-payer push

For years, New York lawmakers have debated a single-payer bill known as the New York Health Act. The proposal, which has seen little movement in Albany since it was first proposed in 1992, would overhaul New York’s health insurance system by, among several other things, eliminating deductibles, copays, and out-of-network costs.

Like in Vermont, much of the debate surrounding the proposal has centered on projected costs.

A 2018 RAND analysis estimated that spending under the New York Health Act would hit $460 billion by 2031, compared to an estimated $475 billion under the “status quo.”

But while total healthcare spending under the legislation could be lower, global policy think tank RAND noted that New York—which is home to almost 20 million residents—would need an additional $210+ billion in tax revenue by 2031 to fully finance the new system. New York collected $118.5 billion from state taxes and fees during the fiscal year that ended on March 31, 2022, according to the state Department of Taxation and Finance.

Backers of the New York Health Act, meanwhile, have estimated that the single-payer system would’ve saved the state about $11 billion compared to the projected “status quo” spending in 2022. Groups that oppose the legislation, like coalition Realities of Single Payer, argue that the New York Health Act would not only raise taxes but also eliminate consumer choice.

State Senator Gustavo Rivera, a Bronx Democrat, introduced a reworked version of the bill in July that sought to gain support from union leaders who had previously voiced concerns about losing negotiated health benefits. The bill is unlikely to move in 2023, as the Legislature adjourned in June.

“With a new legislative year about to begin, I’m making the case that, to make sure our healthcare institutions and providers are financially stable, we need a single-payer system to focus dollars on delivering care,” Rivera said in a statement. “This bill will take a great deal of political willpower to pass, and growing support from our partners in labor is essential because we need an incredibly strong coalition to transform the broken for-profit healthcare system to one that prioritizes patients and providers.”