Single-payer advocates push cause in states; challenges likely

From Vermont to California, proponents of single-payer health care have been busy introducing legislation, circulating ballot petitions and broadening their coalitions -- all with the hope that at least one state will enact legislation that can be used as a model for national health care reform.

But opponents of single-payer health care, including state medical societies, say they are not worried that all of the activity means that government-run health care will be enacted any time soon.

"We're not ringing the alarm bell yet," said Tim Maglione, senior director of legislative affairs at the Ohio State Medical Assn.

Although Ohio has one of the most active single-payer movements in the country, there is little chance that a single-payer bill will pass the state's Republican-controlled Legislature or be signed into law by Republican Gov. Bob Taft.

"We feel pretty confident the Legislature doesn't have any interest in pursuing this," Maglione said.

Single-payer advocates, having drawn the same conclusion, have turned their efforts to a petition drive, said Johnathon Ross, MD, a Toledo internist and a leader of the Single-Payer Action Network of Ohio.

The group is attempting to collect about 100,000 signatures on its petition, which directs the Legislature to vote on the Health Care for All Ohioans Act. So far, they have collected "tens of thousands" of signatures, Dr. Ross said.

If the Legislature then refuses to take action on the bill, supporters will collect a second round of signatures to put single-payer legislation directly on the ballot.

"Our target [for putting it on the ballot] is November 2006 at the earliest," Dr. Ross said. But the group may put it off if they need more time to prepare for what is likely to be a formidable challenge waged by the insurance industry and other opponents, he said. Single-payer ballot initiatives have been tried in Oregon and California but were unsuccessful when they faced the opposition's overwhelming resources.

Single-payer advocates don't want to see that happen in Ohio. "We have to make sure we have a movement" established before taking single-payer health care to the ballot box, Dr. Ross said. "We're using the petition to drive this movement."

In addition to Ohio, at least 17 other states have introduced universal health care measures, most of them based on a single-payer model, according to the National Conference of State Legislatures. But so far, none of the bills has been enacted.

The American Medical Association has opposed the establishment of single-payer health care both at the state and federal levels. It has long advocated for using tax credits and other market-based reforms to make health care coverage more affordable.

Vermont's close call

The state that came closest this year was Vermont, where the Legislature passed a bill in June that would put the state on the road to establishing a single-payer system called Green Mountain Health.

The measure, called an Act Relating to Universal Access to Health Care in Vermont, would have phased in a single-payer system funded through taxes levied on individuals and employers. But Republican Gov. James Douglas vetoed the legislation.

Despite the veto, the Legislature was able to appropriate funds for the Commission on Health Care, a legislative panel that is studying a number of issues related to health care reform, such as governance and financing.

Both the commission and Douglas are holding hearings to solicit recommendations on health care reform. The Vermont Medical Society has been developing its own proposal, which it plans to submit in mid-October, Executive Director Paul Harrington said.

Rather than promote a single-payer system, the VMS proposal would keep in place existing insurance coverage paid for by employers, Medicare and Medicaid. It would offer residents in the individual market a basic benefit plan at an affordable cost through the Office of Vermont Health Access, the agency responsible for the state's Medicaid and other health programs. The proposal also would subsidize premiums for low-income Vermonters and provide new incentives to encourage employers to offer health insurance to their employees.

Eyes on the prize

Of all the states where single-payer supporters are most active, California is considered the biggest prize because of its sheer size, both in terms of population and health care spending. Nearly $200 billion is spent in California each year -- about 13% of the entire nation's spending on health care, according to the UCLA Center for Health Policy Research.

Activists there have been working for years to enact single-payer legislation, but supporters and opponents have differing views on whether the movement has crested or continues to grow.

"As far as we know, their efforts are not any more prevalent today than they were a year ago or 10 years ago," said Larry Akey, a spokesman for America's Health Insurance Plans.

But that's not the view of Ida Hellander, MD, executive director of the Chicago-based Physicians for a National Health Program. The single-payer movement in California "just continues to grow," she said. "They have a pretty broad-based movement; they've educated a lot of people, and very large, well-organized groups like the California Nurses Assn. are on board."

In the California Legislature, a single-payer bill passed the Senate in May but faces an uncertain future in the General Assembly. Even if the full Legislature approves the bill, Republican Gov. Arnold Schwarzenegger is likely to veto it.

"The bill is dead for the moment," said Michael Sexton, MD, president of the California Medical Assn., which opposes the legislation. "We don't think there should be an ability to ration care based on a global budget," he said.

Instead, the CMA is working to advance its own proposal, which would cover the uninsured but preserve a public-private system of health care coverage, he said. The plan includes refundable tax credits for the purchase of health insurance.