Single Payer Redux?

Years ago, the subject of "single payer" surfaced. Single-Payer Lessons from Vermont (July 2016). As noted there, a fair amount of dispute and disagreement in litigation systems does not focus on the notable questions of pathology existence or treatment need. Instead, much time is often spent in the debate of the more mundane question of who pays for the effects of pathology. See Someone has to Pay (May 2016).
Vermont's foray into single-payer was not the first attempt, nor the first failure. The economic realities of free healthcare for all are challenging at best. Some would argue that they are insurmountable based upon the immutable characteristics of human nature and the economic laws surrounding scarcity, supply, and demand. Those are all interesting, as is the humanitarian instinct that argues for the collective good. Students of history sometimes struggle to identify successful socialistic governments, but some socialistic medical systems have survived across the globe. Despite that, there are complaints about virtually all medical systems, socialistic or not. 
The new year brought news of a possible resurrection of the concept. There have been three notable attempts at the concept, and each has failed to thrive. As a 2019 report from Third Way put it:
"What do Vermont, . . . Colorado . . . and Massachusetts . . . , have in common? They’ve all failed at pursuing single-payer."
There are various perspectives on the why and how, but empirically there is currently no active "single payer" jurisdiction in the United States. However, another thing those three states have in common is their absence from the top ten states. According to InfoPlease, Massachusetts is 15th in population, Colorado 21st, and Vermont is 5oth (behind the District of Columbia). Some would argue that the idea has simply not been tried yet on a large enough scale. Others might suggest that size will not change the outcome, merely the size of the failure. 
But, 2021 brought news that Massachusetts might make another run at "single payer." Proponents are citing the challenges and uncertainty that employees faced with the onset of the 2020 Pandemic. As jobs were lost and employment shifted, there were "inefficiencies . . ., fears and concerns . . . when they were in transition." There is therefore, some advocacy in 2021 for socializing medicine again in Massachussets with "Medicare for all."
The news in 2021 also brought suggestion from California that the "single payer" discussion might begin again there. California is a much larger state; number one with a population of almost 40 million people. The population of Massachusetts, Colorado, and Vermont combined is about 1/3 of the population of California.
According to ABC News, the current proposal would come in two parts:
"Assembly Bill 1400 would set up "CalCare," a state-run, statewide system, and Assembly Constitutional Amendment 11 would change the state's tax code to pay for it through a voter referendum."
There is a distinction between the ideal of medical care for everyone and the burden of how to pay for such a plan. California currently ranks 15th in the country by overall tax burden with close to 10% of Californian's earnings going to taxes, according to Wallethub. By comparison, Alaska is rated last at just over 5%. According to Forbes, perceptions of taxes have perhaps driven some of the sentiment of California exodus in recent years.
In that light, there is some room to question whether increased taxes will benefit the state with additional income, overburden taxpayers that may already perceive stress, or further fuel the rate of departure for Texas, Arizona, Nevada, and more. 
ABC reports that there is increased interest in "single payer," and that 63% of Americans support the notion that providing health care is the government's responsibility. The details of how that question has been posed are not apparent. More specifically, the proposal is said to enjoy support of California's legislative and executive branches. However, there is admission that it cannot be paid for within the current constraints of government there.
Therefore, if it is passed, there would have to be "significant tax changes that can only be authorized by a voter referendum" (the amendment noted above). This suggests that any such enactment of "single payer" would be several years in the future at the earliest. The article notes that "single payer" is not new, mentioning the earlier failures elsewhere. It also notes that prior attempts in California have failed to clear the legislature. The latest of these apparently over the "$400 billion price tag" of a 2017 proposal. That is real money even in Dirksen terms ("a billion here, a billion there," or perhaps in context "a hundred billion here . . . "). 
In 2021-22, the entire California state budget, according to the Legislative Analysts Office (LAO) is about $200 billion. So, a parallel path to the 2017 legislation for "single payer" would potentially represent a 200% increase in the state budget. In simple math terms, that would mean that revenue (taxes or fees) would likewise have to increase roughly 200%. And, this hypothesis ignores that the $400 billion figure is five years old and predates the epic inflation that America is experiencing over the last couple of years; with trillions of debt dollars entering the marketplace, there is no prediction for an early end to the current inflation cycle. When Americans are polled regarding whether providing health care is the government's responsibility, one wonders if the question includes disclosure of the tax increases that would be required for such inclusivity and largesse.
In the closing scenes of Blast from the Past (Warner Brothers, 1998), Alicia Silverstone narrates a scene
"It's truly amazing what you can get done when you have unlimited funds. . . .. All you have to say is this 'I don't care what it costs,' and then of course you've got to really mean it."
Of course the fallacy of that is obvious, there is no such thing as "unlimited" anything. The universe is vast, as is California, and yet all things are finite. All resources are limited in at least some context. Theoretically, a government might tax someone 100% of their income, or perhaps even 200%, but eventually that would dry up both the revenue stream and the reservoir from which it flows. And, of course, in the current "single payer" proposal the final limitation will come down to the will of the California voters. Do they "really mean it?" And, if they do, what effect might the ensuing tax increases have on emigration to Texas, Arizona, Nevada, and more? If all the taxpayers move to avoid the burden, how will the remaining residents benefit? 
The "single payer" debate and experiment in California will be interesting to watch in 2022. It seems likely there will be much discussion and debate in the news. Whether the legislature can get over the price tag, or whether legislative action will stall as it did in 2017 will be the issue this year. If that legislation supports the transition, then the voter's decision on expanding, or even tripling the state budget, with the accompanying tax burden, will be the issue in years to come. The debate and discussion will be fascinating to watch, and could be a harbinger for other states' future debates. 
By Judge David Langham
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    About The Author

    • Judge David Langham

      David Langham is the Deputy Chief Judge of Compensation Claims for the Florida Office of Judges of Compensation Claims at the Division of Administrative Hearings. He has been involved in workers’ compensation for over 25 years as an attorney, an adjudicator, and administrator. He has delivered hundreds of professional lectures, published numerous articles on workers’ compensation in a variety of publications, and is a frequent blogger on Florida Workers’ Compensation Adjudication. David is a founding director of the National Association of Workers’ Compensation Judiciary and the Professional Mediation Institute, and is involved in the Southern Association of Workers’ Compensation Administrators (SAWCA) and the International Association of Industrial Accident Boards and Commissions (IAIABC). He is a vocal advocate of leveraging technology and modernizing the dispute resolution processes of workers’ compensation.

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