Could States Do Single-Payer Health Care?

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News Article

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Project HOPE




The Affordable Care Act (ACA) transformed the US health care system by increasing coverage, expanding federal involvement in private health insurance, and changing public expectations for access to affordable coverage. Yet, the ACA did not provide universal coverage and has proven unstable under political and legal attacks since its enactment in 2010. While proposals for replacing the ACA with single-payer health care have attracted national political attention, discussions of a federal single-payer system such as “Medicare for All” remain light on specifics. At the state level, however, state legislators have drafted and introduced dozens of detailed bills to implement single-payer systems. Our study of state single-payer proposals in the ACA era highlights the extent to which states must contort their health reforms to overcome federal legal hurdles—particularly the threat of preemption by the Employee Retirement Income Security Act (ERISA) of 1974—and prompts questions about whether states can actually implement single-payer health care.

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