While the focus of such discussion remains largely national in scope, a handful of Democratic-leaning states have also explored the feasibility of operating single payer health care systems at the state level.
In Massachusetts, where a landmark 2006 health care law created a model for the federal Affordable Care Act, some activists now wonder if the state should continue its pioneering role by becoming a test site for single payer.
That doesn't appear likely in the near future.
State Rep. Jennifer Benson, a Democrat from Lunenburg, says she likes the idea of "Medicare for All." In theory, that is.
"When we move out of the theoretical support of single payer care to the actual implementation, it becomes dicey," Benson told an audience at a recent public hearing at the Statehouse.
Benson's reservations matter greatly because she's the House chair of the Legislature's Committee on Health Care Financing, and any effort to transform today's private health insurance system must be vetted through the panel.
Legislation filed in the House by Reps. Denise Garlick, of Needham, and Lindsay Sabadosa, of Northampton, and in the Senate by Sen. Jamie Eldridge, of Acton, proposes a Medicare for All system in Massachusetts. It has 62 Democratic co-sponsors in the Legislature.
The bill would treat health care as a right, much the same as public education, according to Eldridge.
"If you believe that wherever you live you should be able to access a doctor, in your town or in your area, without paying any bills ... single-payer is the only solution for that," he said.
The bill envisions universal access to quality health care for all the state's citizens "without co-insurance, co-payments or deductibles," and would create the Massachusetts Health Care Trust Fund to administer the program.
The proposal does not offer an estimate of costs, which skeptics say would be enormous, but does lay out specific plans for financing the trust fund, including a 7.5% payroll tax on employers; an additional 0.44% assessment on businesses with more than 100 workers; a 2.5% employee payroll tax; a 10% payroll tax on the self-employed; and a 10% tax on unearned income above $30,000, with exceptions for Social Security, unemployment and pension benefits.
Funding was but one of many logistical concerns expressed during the hearing.
Benson questioned supporters on how the proposed law, which technically would begin taking effect within 90 days of passage, could be implemented in a state without single-payer experience. Would, she asked, the current private system and new public system run simultaneously during a lengthy implementation period, forcing businesses and workers to pay both premiums and new taxes during such time?
Another potential roadblock: Massachusetts would need a new federal waiver to institute Medicare for All and the state's existing waiver doesn't expire for another two years.
Lawmakers backing the plan insisted such obstacles were not insurmountable. Eldridge argued the proposed payroll taxes would amount to less than what businesses which offer health insurance benefits to employees currently pay in premiums.
But supporters at times appeared to acknowledge the long odds facing passage, saying that one of their goals was to start a "conversation" about single payer at the state level.
Legislation filed in more than a dozen states seeks some form of universal health care but so far only Vermont has even come close to embracing such a system. Then-Democratic Gov. Peter Shumlin abandoned efforts to implement a government-financed system in 2014, later conceding it was difficult for states, particularly small ones like Vermont, to go it alone.
"Across the country, single payer health care has been rejected by each state that has given it serious study because the significant tax increases needed to support the system would leave the state uncompetitive, crippling economic growth and job creation," said Lori Pellegrini, president and chief executive of the Massachusetts Association of Health Plans, in prepared testimony before the legislative panel.
So while Medicare for All remains a topic of heated debate in the presidential campaign, Massachusetts lawmakers for now seem likely to put aside proposals for dramatic reform, focusing instead on attempts to rein in soaring health care costs and stabilize financially troubled community hospitals.
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