by Bill Zimmerman

Recently Public Citizen, a member of California’s AllCare Alliance, released a report entitled, “A Roadmap to Single-Payer: How States Can Escape the Clutches of the Private Health Insurance Industry.” “We’re looking for a few pioneering states with the courage and fortitude to let common sense prevail over the insanity of our current patchwork system, “said Lisa Gilbert, director of Public Citizen’s Congress Watch division.  “Once they succeed, we expect most opposition to single-payer and our reliance on privately insured health care to become historical relics.”

The report was welcomed by advocates working in state single-payer movements around the country. In some circles, however, it generated skepticism that single-payer could actually be accomplished at the state level due to the complexity of the waiver processes that states would have to navigate.

The Public Citizen report lays out a long list of bureaucratic barriers that stand in the way, i.e. the need for states to obtain waivers to capture existing federal funding streams, yet in their view these are but policy hurdles. Policy can be changed through the political process, and it is in the political arena that the real decision will be made about whether or not state single-payer is viable.

From a political perspective, as difficult as change at the state level might be to imagine, the thought of accomplishing single-payer in Washington, DC is even less credible.  There you would have to first overcome the current partisan polarization that precludes compromise, something that will simply not happen in the near future and is very difficult to imagine in any foreseeable future.  Even if such an illusive goal were achieved, health insurance companies and their allies would still be able to buy support in the form of campaign contributions and lobbying muscle, and not just from Republicans/conservatives, but as history has amply demonstrated, from many Democrats/liberals as well.

The political environment in California, however, is more favorable. California is a solidly blue state with a large and increasingly influential immigrant population that would benefit greatly from universal health care.  Currently California has a Democratic governor and a legislature with a Democratic supermajority in both its houses. In fact, it has already twice passed a single payer bill – the only state in the nation to do so (with deference to Vermont, which passed a “roadmap” to single payer in 2011).  To be sure, California has its share of “corporate” Democrats who would oppose single-payer, but voters here also have the option to bypass state government entirely and pass single payer through a ballot initiative instead.

The states historically have been laboratories for testing new policies, and California has often been the leader, stimulating new progressive state and federal laws in a wide variety of policy areas.  Examples include auto emission standards, gun control legislation, disclosure of carcinogens, banning toxic fire retardants, medical use of marijuana and drug treatment instead of incarceration.

Tipping points often play a role in politics.  Some issues look impossible until they become inevitable.  Gay marriage is the prime example, but so too are tobacco cessation, seatbelt use and marijuana legalization.  Soon climate change issues will have to join that list.  We all know there will be difficulties bringing ACA on line.  Those difficulties could be the impetus that forces a reconsideration of single-payer, and tips the balance in our favor.  In any case, it is hard to dispute the idea that political change can be more readily achieved in Sacramento than in Washington, DC, given the absence of comparable polarization and the greater potential impact of grassroots pressure.

Passing single-payer in California could be the best avenue for achieving it nationally.  Gay rights advocates organized a well-coordinated state strategy on marriage equality that has led to a veritable domino effect of states rushing to extend civil rights. The Supreme Court considered the obvious change in public opinion and state law when they struck down the oppressive federal Defensive of Marriage Act last month.  A successful, if limited, single-payer system in California could easily have comparable cascading impacts across the nation and in Washington, DC.

By the time California votes to move to a single payer system – the earliest date possible is 2017 when the Affordable Care Act allows states to set up their own systems – Congress will have gone through two more election cycles. Voters will be less white, and probably less conservative, and the changing composition of the House of Representatives may allow for passage of single-payer waiver legislation for states, perhaps even with “state’s rights” support from a few Republicans.

California, Vermont and possibly other states moving to single-payer will put increasing pressure on Congress to grant other state waivers.  Once subject to such pressure, Congress could theoretically pass a federal bill to give (improved) Medicare to all, but it is politically far more likely that they will simply let the states set up their own systems, which can then become models for a larger federal program.  California, once again, could be the engine driving national change.

Bill Zimmerman is president of Zimmerman & Markman, Inc., a political consulting firm based in Santa Monica.  He has led several dozen ballot initiative campaigns in California and across the nation, including landmark victories for physician-assisted suicide, mental health funding, drug treatment in lieu of incarceration, and medical marijuana.  He is the author of Troublemaker: A Memoir from the Front Lines of the Sixties.”

Re-posted with permission from