While the debate on whether to repeal the Affordable Care Act remains one of the main priorities at the federal level, another debate is brewing in New York: Is a single-payer system really a viable option for New York?
The recent efforts by Republicans in Washington to repeal ACA would a have a huge negative impact on New York, as the state wholeheartedly adopted the ACA and is at risk of losing significant funding from the federal government and many citizens are also at risk losing coverage. As a result, Gov. Andrew Cuomo, for the first time, made public comments in support of a single-payer-type health care system.
“If they were to pass it and it was not incongruous with what the federal government would do to us, I think it’s a very exciting possibility,” Cuomo said on The Brian Lehrer Show on Sept. 18. “But I think it’s going to be a federal play. Our funding system basically relies on Medicaid from the feds. If they turn off that valve or slow that valve, there is no way we’re going to be able to make that up in this state no matter what.”
Proponents for a single-payer or “Medicare for All” system took Cuomo’s recent statements as a huge victory for the moment that has long been an idea, but has failed to gain traction.
In recent months, a single-payer system has gained enormous public support. U.S. Sen. Bernie Sanders ran for the Democratic presidential nomination supporting the idea and recently U.S. Sen. Kirsten Gillibrand and other Democrats have also thrown their support behind his bill.
Assembly Health Committee Chair Dick Gottfried has sponsored single-payer legislation in the Assembly since 1992.
“The single-payer/Medicaid-For-All concept has gained an enormous level of support among the public and elected officials that we’ve never seen before,” he told The Alt. “I think the fact that (Cuomo) believes in principle that it’s a good idea and says so is a huge step forward. I believe we can convince him and his health policy people that the overall savings are real, and in the weeks and months ahead, we will be working on that.”
Proponents directly point to the current efforts to repeal the ACA as a reason to support a single-payer system.
“I think it’s related, people are seeing an unrelenting assault on health care coming from Republicans in Washington and I think that is making people look for alternatives,” Gottfried said. “If health care is a right then you should not face individual financial obstacles to obtain it. It should be treated as a public good and paid for through a broad-based, fairly distributed tax based on ability to pay.”
New York Medicaid Director Jason Helgerson agreed with Gottfried’s assessment and had harsh criticism for the recent repeal efforts, specifically the Graham-Cassidy repeal bill that recently failed on the federal level. Helgerson has been director since 2011 and before that was Wisconsin’s Medicaid director.
“The real disgusting aspect of this is that this latest version was designed to take money away from New York and give it to other states, explicitly in order to buy votes and so they could hobble together the 51 votes they needed so they in essence tried to bribe other senators to vote for it,” Helgerson said. “It almost seems that with each version that comes out basically is worse and worse for New York.”
Helgerson said the recent Graham-Cassidy bill would have cut federal health care funding for New York somewhere from $40 to $60 million between 2020 and 2026, which would “devastate” the state’s health care system and ultimately lead to many citizens losing coverage.
Another aspect less talked about, Helgerson noted, is that in many communities in New York, health care providers are one of the largest job providers. The federal funding cuts could cause providers to shut down, leading to significant job losses for the state.
Gottfried’s bill has repeatedly passed the Democratic-controlled Assembly in recent years, but has never brought to a vote in the Republican-controlled state Senate and still faces significant opposition from the business community.
“In a world in which resources are limited always and everywhere, this bill’s promise of universal, unlimited coverage is a mirage,” Lev Ginsburg, director of governmental affairs for the Business Council, said in a statement last February. “Single-payer systems inevitably must keep costs lower by rationing care, not by being more efficient. In this ‘free-for-all system,’ costs are driven up by patients over-consuming perceived ‘free’ health services and the rationing of these services follows.”
Even within Cuomo’s administration, policymakers are supportive but skeptical of how viable a single-payer system is. Helgerson pointed to Vermont’s efforts to adopt a single-payer system.
Back in 2014, a single-payer system had the support of many Vermont state lawmakers and the governor. Helgerson said Vermont got closer than any other state in recent years to passing single-payer, but ultimately was faced with a harsh reality: There was no way to pay for it.
Cuomo signaled support for both a federal- and state-level single-payer system, but did note the need for federal support. Helgerson said single-payer is not a viable option without federal funding.
“The challenge that a state would have is that we do not have the ability to deficit spend, so we have to balance our budget every year and I think the concern is that it may be difficult for state government on its own to be able to do that within our limited budgetary arrangements,” he said. “What I think (Cuomo) was signaling was some interest in finding a way for the nation to get to a single-payer solution that, overall, would lead to more cost-effective system, universal access to services and that’s really what he was suggesting.”
While Helgerson is supportive of the idea, but as the state’s Medicaid director, said there was no way for New York state to solely be able to fund a single-payer system through taxes, as the cost is too high and the burden would be too significant on citizens.
Gottfried disagrees. A single-payer system would ultimately lead to savings in the health care system, and funding would come from a payroll tax that would be progressively graduated on the ability to pay and thus would be affordable for New York, he told The Alt.
“New York has per capita about the biggest tax base of any state,” the assemblyman said. “Under existing federal law, there are a variety ways to merge the Medicare program into a single-payer system. Merging Medicaid into it is easy because we run Medicaid.”
He added that savings from a single-payer system would also offset the costs.
“The money we save by getting rid of insurance companies will be more or less than the increased utilization, because we’re covering the uninsured, for example,” Gottfried said. “Those are questions that could be argued about. But to say, ‘Oh my God, we can’t do it, because you’re going to double the state budget,’ that’s ridiculous. We’re already spending double the state budget on health care in New York state.”
As Gottfried noted, next year’s state legislative session will be one to watch to see if the single-payer debate progresses. It is widely rumored that Cuomo has presidential ambitions for 2020, and a major progressive move on health care could give him a boost. Cuomo already has touted his progressive credibility by raising the minimum wage, pushing the most restrictive gun-safety laws in the country and passing marriage equality during his two terms.
For those more cynical about politics, even the current federal health care debate may have an upside.
“I do think that if the Republicans decide to rue the day and decide to take such an assault on the Affordable Care Act, is that what is absolutely true is that it has lit a fire in support – particularly in the left side of the spectrum – for a single payer type solution,” Helgerson said. “There’s more interest, more excitement, more energy around that topic than I can ever remember.”