Health policy expert and single payer supporter Uwe Reinhardt said in a recent interview with the Washington Post that the United States won’t ever have single payer “because our government is too corrupt.” Reinhardt points the finger at special interest lobbying as the culprit:

“When you go to Taiwan or Canada,” Reinhardt said, “the kind of lobbying we have here is illegal there. You can’t pay money to influence the party the same way. Therefore the bureaucrats who run these systems are pretty much insulated from these pressures. Here you have basically a board of directors in the House Ways and Means Committee that gets money from lobbyists both at the regulatory writing stage and during normal operations. And they can call an administrator and demand they stop something from happening.”

True, money in politics is an underlying factor in America’s failure to enact the kind of not-for-profit, universal healthcare system enjoyed by the rest of the developed world. But Reinhardt only has it half right. The corrupting influence of money in the United States is not the complete picture. The political power imbalances between the majority of the American public who support Medicare for all and those who resist meaningful healthcare reform is equally to blame.

Many liberals have criticized President Obama for not vigorously supporting a single payer system or even the idea of a public option when healthcare reform was being bitterly debated in Congress in 2009-10. Some blame the Republican takeover of the House of Representatives in 2010 on voter disenchantment with the legislative sausage making that produced the Affordable Care Act. But, putting the blame entirely on Obama and the Democrats for the failure of single payer on the federal level is misplaced. The sad fact is, as much as progressive activists wanted to see single payer or a public option enacted at the federal level, the nature of American politics today makes that feat extremely difficult.

Some liberals like to point out that the Democrats had enough votes in Congress in 2009-10 to pass at least a public option. On its face, that’s true. The House had passed the public option, but the problem was in the Senate. Where although a simple majority supported a public option, Senate filibuster rules allowed a determined minority to torpedo more progressive legislation that would minimize or eliminate the role of the health insurance companies in our healthcare system. Combined with a healthy dose of health insurance campaign cash, Senate filibuster rules empowered a minority of legislators from more conservative, sparsely  populated states to thwart the majority. This kind of power imbalance is also evident in battles over other kinds of legislation, from gun control to increasing the minimum wage to expanding unemployment insurance to immigration reform.

The reality is that America’s electoral system creates unique barriers to progressive legislation. Unequal political representation is baked into our system and has gotten worse over time as more Americans have migrated away from rural areas and concentrated themselves into cities where their voting power is diluted. Today, we have the perverse result of red state Wyoming with just under 600,000 people having the same number of votes in the Senate as blue state California with nearly 40 million people. In the House, the 2012 election resulted in Republicans capturing 234 seats although they got fewer votes than Democrats who got only 201 seats. The division of power between the President, who may be from one party, and the Congress, which may be controlled by the other party or split between both parties, creates the likelihood of legislative gridlock. Partisan gerrymandering, Senate malapportionment, entrenched incumbency, the division of power between two ideologically opposing parties, the complete shutout of third parties, combined with the polluting influence of special interest money, all contribute to legislative paralysis or to the passage of legislation that is far from what most Americans want. Further, voter participation rates are far higher in other democracies where access to the ballot box is considerably easier than in the United States. Add to the mix America’s troubled racial history when it comes to the provision of social programs, and you have among the skimpiest social safety nets of any developed nation.

It doesn’t matter that polls have consistently shown that a majority of the American public supports universal Medicare, a legislative minority backed by health industry lobbyist money can take advantage of undemocratic and arcane Congressional rules, as well as Constitutional anachronisms that unfairly magnify the political power of the minority, to get single payer put off the table. I often wonder why many activists hold up the problem of money in politics as the main reason why popular ideas like single payer can’t get passed at the federal level, but gloss over the fact that glaring structural flaws in America’s political system are just as problematic. Perhaps it is due to a particular American loyalty to the ways we do (rather, don’t do) democracy and a nearly religious reverence to a Constitution that is rather shop-worn. Or it may be an ignorance of how other countries practice democracy differently (and perhaps, better) than we do. Or it may have much to do with the extreme difficulty – if not near impossibility – of getting any sort of institutional change in America, let alone remaking the political system altogether to make it fairer. The movement to amend the Constitution to get money out of politics and strip corporate personhood is going full steam ahead, but four years and two general elections after the Supreme Court’s Citizens’ United decision, we’re still a long way from getting 2/3 of Congress and 3/4 of the states to agree to pass an amendment as required.

Since Washington is hopelessly broken, it’s up to the states to take the lead on single payer. States, Supreme Court Justice Louis Brandeis once said, “are laboratories of democracy.” They can also be laboratories of health reform. The states aren’t as legislatively constrained as the federal government. Vermont was the first to  say yes to single payer. There are strong single payer movements in California, New York, Oregon, Pennsylvania, Maine and Maryland. The Affordable Care Act’s flaws and its troubled rollout have led the public to give single payer a second look. Fortunately, the ACA does provide the states with the means to implement single payer on their own. In 2017, states can apply for a waiver enabling them to create healthcare systems apart from the ACA as long as those programs cover as many or more people than the federal law. We already know that single payer will cover everyone in America for less money than our current wasteful for-profit healthcare system. A successful single payer system at the state level will more easily open the doors toward a national universal healthcare system.