The US can do the same, this doesn't have to be all-or-nothing at the Federal level.
US States are
1) far more powerful than Canadian Provinces, to the extent that anything not explicitly delegated to the Federal government by the Constitution is left to the States (10th Amendment)
2) nearly every single state in the US has a GDP per capita on par with whole European nation-states, which is more than enough to fund a single-payer system
So essentially, de jure States and Provinces are more or less equal in autonomy, but in practice Provinces have much more sovereignty.
The economies of scale that make public healthcare work require you to either control the market or a significant portion of it in order to strong arm the suppliers, A few US states such as California might be able to, but the Federal government would very likely interfere.
Besides Medicaid, the vast majority of State-administered services are paid for through State taxes — a combination of income, sales, and property taxes. The vast majority of Federal taxes go toward Medicare, Social Security, the US Military, and Medicaid — all of those comprise 80% of the Federal budget. Besides Medicaid, none of those other things are State-level programs.
> This means that the Federal government, if it disagrees with a decision of a State, can cripple it by withdrawing funding.
This only applies to Federal highway funding. The Federal government has little control over how States fund their public K-12 schools, public universities (for eg Georgia funds its University system by taxing the lottery), electricity, water, sewage, police departments, fire departments, local public transportation, or public libraries. Further, the Federal government recently cut taxes, making way for States to fill in the gap to further cement control over their own finances. In fact, there is nothing stopping States from increasing the marginal tax rate back to WW2 levels.
> So essentially, de jure States and Provinces are more or less equal in autonomy, but in practice Provinces have much more sovereignty.
Not sure how you think this. US States are arguably more sovereign than Canadian provinces. The States exert more control over the affairs of the Federal government through its equal representation in the Senate. While Canada also has a Senate, in reality, it's like the Queen in that it totally lacks democratic legitimacy and could not actually stop major legislation from the House of Commons without sparking a Constitutional crisis. The Senate basically can force the Commons to vote on amendments, but does not block the government's agenda. This is simply not the case in the US.
Every State has its own Constitution, Legislative Branch, Executive Branch, and a State judiciary that enforces its own Constitution. Most US States even have their own military[1]. Americans are Constitutionally citizens both of the Federal republic and of the state in which they reside.
> The economies of scale that make public healthcare work require you to either control the market or a significant portion of it in order to strong arm the suppliers, A few US states such as California might be able to, but the Federal government would very likely interfere.
Yes, and every state has the ability to do this. Pharma providers, Hospitals, and doctors would be forced to accept a State single payer insurance plan, or they would have to either leave the state or go out of business. A provider in Chicago isn’t competing for patients in Florida. Pharma companies that supply medicine and supplies can either decide to accept lower revenues in a State, or stop operating in the state. The resulting vacuum from doing so presents an opportunity for new Pharma entrants (perhaps even homegrown in those states).
During FY2019, the federal government awarded 9,989 grants, 181,947 contracts, and made 99,148 direct payments to people and organizations in Georgia. This includes $630M from the NIH, at least a billion dollars from the Department of Education, and about three billion more from the USDA. Some of this might happen anyway--the DoD is not going to stop buying stuff from Lockheed any time soon--but a lot of this could be cut off if a state decided to go its own way.
Meanwhile, in Canada, one province has decided to pick its own official language, rolled its own tax scheme, and spent five years trying to opt every law out of federal court via the "notwithstanding" clause (and then used it twice more anyway).
Grant numbers from:
- https://report.nih.gov/award/index.cfm?ot=&fy=2019&state=GA&...
- https://www.usaspending.gov/#/search/3b17d170c1cf87cac2f307d...
And for the sake of argument, let’s say that withholding funding from random institutions that happened to have branches situated in a particular state is an effectively targeted attack, the Georgia state budget is $48B, and there’s more than enough room for Georgia to raise its own taxes.
US States also have the ability to set their own languages, including Hawaii and Alaska. Every state has the ability to set its own tax scheme. Alaska has its own sovereign wealth fund.
"Get with the program, or we're moving the CDC/National Primate Center/etc to Rayleigh-Durham" would certainly get some state politicians moving. Not only is that a lot of money, but those are also good jobs and prestigious institutions. I agree that totally cutting off funding from an agency would be unlikely, but it's not totally unprecedented (55 mph speedlimit and raising the drinking age). And of course, there's the middle ground of changing priorities with a wink and a nudge.
As for language, no. A national language has been politically fractious in the US for decades. States do have them but they're all English, with some symbolic concessions to indigenous peoples' languages in a few states. Alaska's law, for instance, "does not require or place a duty or responsibility on the state or a municipal government to print a document or record or conduct a meeting, assembly, or other government activity in any language other than English." I doubt many people are renewing their drivers' licenses in Lakota or Hawaiian.... Compare this with Quebec, which requires that both official languages be used federally, and not only doesn't use one of them, but even has an office devoted to ensuring that the other isn't too prominent in provincial government or daily life.
Likewise, states certainly can set their own taxes and level of social services, but Quebec itself has tax and social service treaties with other countries. Quebec also runs a parallel immigration system (selection/admission) that again, has treaties with other, mostly francophone, countries. No state in the US does anything like this; in fact, it's explicitly forbidden by the Contracts Clause (Article 1, Section 10).
I'm struggling to examples where US States are stronger than the federal government or their Canadian counterparts. In theory, the 10th Amendment suggests that they could be, but US v. Sprague and Darby Lumber Company basically gutted that idea: the reserved powers clause "added nothing", "states but a truism", etc. In practice, the Commerce Clause and Supremacy Clause let the federal government do nearly anything.
Georgia budget figures from here: https://ballotpedia.org/Georgia_state_budget_and_finances)
Alaska language law: http://www.legis.state.ak.us/PDF/28/Bills/HB0216B.PDF
Quebec-France tax treaty: https://www.revenuquebec.ca/en/citizens/your-situation/new-r...
Quebec vs. Canada Immigration: https://www.immigration-quebec.gouv.qc.ca/en/immigrate-settl...
The Federal government has no right to rescind bonds to States, any more than they have the right to rescind bonds to foreign entities — the stability of US Treasury Bonds is predicated on the Federal government's reliability as a creditor. States also have the ability to issue bonds to pay for programs. Georgia enjoys a AAA rating, one of the highest credit ratings in the Union.
Also, we're just talking about Georgia here, the Federal "aid" as a %age of revenue varies from State to State.
Also the structural gridlock built into the Federal government swings both ways, and you need a filibuster-proof majority in the Senate too be able to do what you're proposing, for instance, decide to cut off Medicaid funding writ large, just to spite certain states. The minority rights baked into the Senate make it incredibly difficult for the Federal government to come down hard on any individual state, in the same way that it makes it difficult for the Federal government to pass laws even if we were able to eke out a simple majority support for that issue.
> "Get with the program, or we're moving the CDC/National Primate Center/etc to Rayleigh-Durham" would certainly get some state politicians moving. Not only is that a lot of money, but those are also good jobs and prestigious institutions. I agree that totally cutting off funding from an agency would be unlikely, but it's not totally unprecedented (55 mph speedlimit and raising the drinking age). And of course, there's the middle ground of changing priorities with a wink and a nudge.
First of all, as mentioned above the Federal government doesn't really have unchecked power to jsut decide to up-and-move the CDC. Second of all, you've given me such an example to demonstrate leverage over Georgia, specifically, but the Federal government has no such leverage over nearly every other State. The States most likely to spearhead a State-level single payer program are probably New York, California, Washington, and Illinois. The Federal government doesn't really have much over them.
> As for language, no. A national language has been politically fractious in the US for decades. States do have them but they're all English, with some symbolic concessions to indigenous peoples' languages in a few states. Alaska's law, for instance, "does not require or place a duty or responsibility on the state or a municipal government to print a document or record or conduct a meeting, assembly, or other government activity in any language other than English." I doubt many people are renewing their drivers' licenses in Lakota or Hawaiian.... Compare this with Quebec, which requires that both official languages be used federally, and not only doesn't use one of them, but even has an office devoted to ensuring that the other isn't too prominent in provincial government or daily life.
I'm not sure what you are arguing here. First of all, we're not talking about a "national language", we're talking about the structural authority for States to define their own language...and there is literally nothing stopping the State of Texas from adopting Esperanto as its State language, if that was something that a majority of its citizens wanted. It just so happens that the majority of citizens everywhere are fine with English, and don't want to change that. Comparing this with Quebec doesn't really prove a point, because you're just giving me an example of a Province that has chosen to exercise this authority. I'm arguing that the US States have the same authority, but simply choose not to exercise it because there isn't the same political will. And further, while Canada recognizes official languages Federally, the United States does not — there is no official Federal language — and it's because this is one of the many matters left to the States.
> Likewise, states certainly can set their own taxes and level of social services, but Quebec itself has tax and social service treaties with other countries. Quebec also runs a parallel immigration system (selection/admission) that again, has treaties with other, mostly francophone, countries. No state in the US does anything like this; in fact, it's explicitly forbidden by the Contracts Clause (Article 1, Section 10).
Sure, again not really relevant to State single payer. And also practically, US States also enter into agreements with foreign entities, one example: California has a cap-and-trade agreement with Quebec. Over the last half-century, states and cities have concluded hundreds to the thousands of agreements with foreign national and subnational governments on a wide range of topics, including trade, tourism, transportation, family issues, sister-sister relations, security, traffic regulation, the environment, and agriculture[1]. Anyway, none of this is really relevant to the discussion at hand — that the level of sovereignty granted to the US states is more than sufficient to enact their own healthcare systems.
> In theory, the 10th Amendment suggests that they could be, but US v. Sprague and Darby Lumber Company basically gutted that idea: the reserved powers clause "added nothing", "states but a truism", etc.
Not really sure how US v Sprague is relevant here, it pertained to the language behind the Article V ratification process. US v Darby Lumber merely state that the Federal government has the right to regulate employment contracts. There's no dispute there, my argument is that States share sovereignty with the Federal government, and States also have the right to regulate employment contracts.
> In practice, the Commerce Clause and Supremacy Clause let the federal government do nearly anything.
Yes, again, the Federal government is empowered to do anything. But so are the States! The Federal government is empowered to start a Federal university system, or a Federal public school system, or a Federal fire safety system, but that doesn't mean that States are prevented from doing those things. The argument here is that, absent the political will to do something at the Federal government, States are empowered to step up. That's what the rigid system of checks and balances with minority rights at the Federal level encourages.
> I'm struggling to examples where US States are stronger than the federal government or their Canadian counterparts.
There are many. Sanctuary laws are one such example. The current Federal government is trying to come down hard against States that have sanctuary laws, but it hasn't really had much luck. Marijuana legalization is another example, it is still technically criminalized at the Federal level, despite being legal in a growing handful of States. The Federal government is empowered to set emissions standards, but States are also empowered to do this, and may even set standards stricter than those of the Federal government, which is exactly what we see happening in California. Net neutrality is perhaps the most recent example, where the courts ruled that the FCC does NOT have the authority to preempt state net neutrality laws[2].
Also, taking a huge step back, we are talking about States deciding to enact their own Single Payer healthcare systems — there is practically no reason for the Federal government to ever withhold funding for anything over that (indeed, Republicans encourage it), the gridlock baked into the Federal government makes that practically difficult, and the States that are most likely to enact such systems are those that have already historically exercised disobedience against the Federal government — to the extent that exercising a State's constitutionally held right to pass their own healthcare laws can even be construed as "disobedient".
[1] https://eelp.law.harvard.edu/2019/11/californias-cap-and-tra...
[2] https://arstechnica.com/tech-policy/2019/10/net-neutrality-s...
Where I disagree is that the states are generally on par with the federal government or their Canadian counterparts.
I gave some examples showing that this isn’t the case, legally (the upshot of those cases, if not the actual subject matter) or practically. The counterexamples you provided are’s compelling. In some cases the supporting facts are wrong (most of that $14B is not in bonds and the federal government can move agencies at will; in fact the USDA just shifted tons of people to Kansas). Others may be legally possible but are so politically implausible (Texas switching languages and dragging the federal government along). The Cap-and-Trade Agreement is on uncertain legal ground, even though cross-border part is comparatively weak. No argument that states do have powers, though sanctuary cities and marijuana legalization strike me more as selective enforcement/picking battles than actual reserved powers.
Personally, I would very much like better healthcare and action on climate change, but I think it’ll need national coordination and I’m skeptical that the states can force that, even if they can sometimes slow-walk proposals forcing them to do things themselves.
I mean, that's the whole point. If you can't even muster up the political will to do something at the state level, especially in deep-blue states, what hope is there of doing it at the Federal level? States need to prove that ideas work by actually trying them out and finding the right implementations.
> Where I disagree is that the states are generally on par with the federal government or their Canadian counterparts.
The argument is that States are on par with the Federal government and Canadian counterparts as it relates to healthcare policy and taxation, and I'm yet to hear a convincing argument to the contrary. Saskatchewan was able to enact single payer in 1947 despite being 1/20th the population of Canada at the time. Its ability to enter into relations with foreign governments or its political will to set a Provincial language is completely irrelevant to that.
> Others may be legally possible but are so politically implausible (Texas switching languages and dragging the federal government along).
The argument is about the structural right, not the political feasibility of it — and also nobody is arguing for dragging the Federal government along, even for healthcare.
Personally, I would actually like to see States try out different approaches to healthcare — Denmark-style single payer, Germany-style public/private hybrid, Switzerland-style individual mandate, Singapore-style HSA-driven care — so that we can have empirical data to prove which systems are superior.
New York has neither of these options.
They also aren't reliant on funding from the U.S. Federal Government, which is a big deal in this case.
> They also aren't reliant on funding from the U.S. Federal Government, which is a big deal in this case.
Besides Federal highway funding and Medicaid, neither is New York. New York's single payer system can be funded entirely through an increase in its own state tax rate — there's a lot of room to increase taxes back to WW2-levels, and a lot of room to raise the middle class tax-rate to Europe-levels.
https://www.washingtontechnology.org/
Should probably be more of these, cooperatives, and foundations that work on software to support bootstrapping.
It's not being talked about much because it is unpalatable to the pro-big-business arm of the Democrat establishment. And you cannot find a more pro-establishment candidate than Biden.
We'll get a chance to try again in four years.
Either way, we pay a lot more for a very subpar health ecosystem compared to the rest of the world.
The argument for single-payer hinges on the theory that the profit motive is incompatible with the very idea of insurance (that is, as long as denying services is more profitable than providing them, an insurance market is an inefficient way to provide said services).
1) "Single payer" is not the only way to deliver universal healthcare. Germany, Switzerland, Netherlands, Singapore all have thriving multi-payer systems. In Switzerland and the Netherlands, ALL insurance is private. In Singapore, while the government covers catastrophic care, 70% of total health expenditures are private.
2) The biggest problem in the US is that healthcare is just more expensive, and American insurers end up having to pay more. An example: doctors in America earn more (PPP adjusted) than in any other country. MRI's in America cost more (even on the Medicare fee schedule) than almost any other country. A lot of this is actually caused by a series of well-intentioned policies passed over the last half century.
3) In the US, for-profit insurance profit margins are a pretty meagre 5%, which doesn't really make a dent in costs. Also, some of the biggest insurance providers are non-profits (Blue Cross Blue Shield, Kaiser)
4) Medicare fee schedules aren't that much better, in fact the part of Medicare that's actually working the best is Medicare Part C (Medicare Advantage), which relies on private payers.
Source: I work at a claims adjuster
Additionally, providers themselves are starting to charge out-of-network rates that are LOWER than Medicare fee schedules. For example, Wal-Mart has launched healthcare in Georgia, charging $25 for a cleaning[1], which is significantly lower than the amount for a cleaning (procedure code D1110) set by Medicare/Medicaid. You can look it up yourself by visiting the FAIR Health code lookup tool (https://www.fairhealthconsumer.org/dental/results), and setting the ZIP code to that of Carlton, GA (location of the Wal-Mart clinic), 30627. The average allowed amount is $64.
Finally, the US government has historically been pretty bad at setting prices, as a monopsony buyer. The US military spends more per capita on the military largely because it pays more per-soldier, per-fighter jet, etc than any other nation on the planet. You would think that, as the sole buyer of US defense sector fighter jets, it could negotiate better rates. The F-35 is expected to cost $1.5 trillion (!!) over its lifetime, and the US enjooys monopoly/legislative powers over that cost.
Another example: NASA's planned SLS moon mission is a bit of a disaster — way over budget and way behind schedule. Because the boosters aren't reusable, each launch is expected to cost $1B (with a B) dollars — EACH launch! Meanwhile SpaceX's target cost-per-launch is $50M.
So while you're right that, in theory, a monopsony can extract the lowest possible price, there's absolutely no guarantee of this, indeed American empirical evidence has at times proven otherwise.
[1] https://www.bloomberg.com/news/articles/2020-02-25/walmart-t...
I can tell you ALL about M4A vs private insurance, I currently work at a claims adjuster, and adjust claims myself.
Or if that's too ambitious, how about just knowing that insurance isn't going to deny coverage just because I went to the wrong clinic/hospital? Nevermind that if I've been in an accident I'm not exactly going to be able to choose where I go.
Yeah this is definitely a worthwhile policy solution. Universal catastrophic coverage would also be a pretty solid compromise, especially since that would essentially be "single payer" for financially ruinous treatments. Ambulance ride costs are indeed insane, and something that even municipal cities can (and should) operate for free just like fire departments.
> Or if that's too ambitious, how about just knowing that insurance isn't going to deny coverage just because I went to the wrong clinic/hospital? Nevermind that if I've been in an accident I'm not exactly going to be able to choose where I go.
Yup, also a great solution. I work at a claims processor and have processed claims myself — the current system is asinine. Simply ensuring that all providers charge the same rate to all patients, and for that charge to be transparent upfront can probably go a long way to improving the status quo.
Single payer means everyone has a health card entitling them to spend tax money on their own healthcare how they want (within certain parameters, of course). This means health insurance companies don't get to act as cartels, limiting (patient) access to care, and, crucially, limiting provider access to patients & patient dollars. If I want to see a doctor in Toronto, I don't go to the doctor "in my network", probably at a big practice that has some convoluted agreement (or not!) with my particular insurance provider. If I want to see a doctor in Toronto, I can basically go to any available doctor who is taking new patients.
Imagine literally everyone has a health-care budget to spend, regardless of how rich poor they are. Can you imagine the type of competition & innovation this creates for those health-care dollars? Pharmacists remember my name & ask whether the meds worked as expected, doctors will visit me at my house (this has been cut back by the latest provincial government), I can check wait times at drop-in clinics online & book an appointment, see a doctor same day, even within a couple hours. Try that in the USA without going to the ER, and even then I'd be surprised if you see a doc in less than a few hours.
I was amazed to see the competition and market innovation in healthcare in Canada when I arrived here. You might be amazed as well.