Collapsing the silos: Structural challenges pose greatest obstacle to proposed California single payer system
Update: The Sacramento Bee reports today SB 562, the single payer measure discussed this post, has been designated a two-year bill to allow lawmakers more time to work out the details into 2018.
California is considering legislation that if enacted, would make the largest state the first in the nation to implement a single payer system for all medical care rendered to Golden State residents. It faces enormous obstacles.
The first is the deeply entrenched (since at least the 1940s) scheme of paying for medical care for most working age families though employee benefit programs. Both employers and employees complain about the rising cost of these programs. But they are heavily tax advantaged for employers, particularly larger ones who offer them to attract and retain employees despite the cost.
The second and related major challenge is America’s fractured medical care finance system with its numerous silos, each with separate eligibility, payment and reimbursement rules. The proposed Healthy California program is inherently radical in that it would have to somehow collapse all of those silos into a single one.
Easier said than done. When it comes to the federal Medicare program that covers those age 65 and older, that could require a change in federal statute to accommodate what would effectively be a state opt-out while retaining the federal program funding. It’s not clear the federal government would be inclined to allow states to do so since this is a federal – and not state – entitlement program. Medicaid is a different story. It’s a joint federal-state entitlement program. As such, the feds have historically accorded states substantial leeway on how they administer their Medicaid programs and set eligibility standards. Then there are program silos for veterans, active and retired military families and interstate employer and union plans.
Reshaping this fragmented landscape into a unitary scheme would require an enormous amount of shared political will both within California and the federal government in order to make single payer a reality. It’s far from clear that it exists. California policymakers may have to reduce the scope of the single payer legislation to cover those under age 65 who are:
- Not offered employer group benefit plan (possibly with employer or employee option to select instead of employer plan)
- Medicaid only eligible
- Self employed.
Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email