Health care is among the top three concerns that Democratic voters hold as we enter campaign season for the 2018 mid-term elections.

The United States spends double the amount per person than other wealthy countries for worse health outcomes, and the cost of care has increased faster than the general economy since 2009, according to the Kaiser Family Foundation.

The 2010 Affordable Care Act extended coverage to millions of Americans, but the number of working-age uninsured people rose by 4 million between 2016 and 2017, likely due to moves by the federal government, according to The Commonwealth Fund, a health care think tank. That could get worse in 2019 after the individual mandate, that bound “young invincibles” to the market to balance out the cost of insuring the elderly and infirm, is repealed as a result of the Republican tax plan. Avalere, a private research company, found that those purchasing insurance on state health exchanges could see significant increases in 2018.

In Iowa, premiums shot up 69 percent in the state’s health insurance exchange, Avalere found.

In the private market, the average 60-year-old purchasing the lowest-cost silver plan was expected to pay $1,875 a year more in 2027 than before the Trump administration repealed the individual mandate, according to a November 2017 analysis by the Commonwealth Fund.

Progressives and liberals are taking a real look at single-payer health care. It’s not just folks with roses in their Twitter avatars anymore — the phrase “Medicare For All” has taken root in leftist candidate platforms across the country, and groups in deep-blue Washington and California are pushing forward with actual legislation.

Initiative 1600, filed by a group of volunteers and supporters called Whole Washington, aims to create a fund that will allow Washington residents to sign up for healthcare in 2020. The first year would be spent setting up the new system. Supporters say that the plan would not just provide Washingtonians with better health care than they have now, but it would actually save the state between $9 and $11 billion in the first year if fully established in 2019.

The plan seeks to take advantage of the existing network of private health care providers while simplifying the financing mechanism to achieve efficiencies, said Erin Georgen, chair of Whole Washington’s initiative writing committee.

“Right now, we have a giant apparatus to coordinate with,” Georgen said. “There are a variety of requirements for reporting to get the coverage reimbursed. That’s primarily where the savings come from.”

Georgen is a health professional, and she’s seen the inside of the beast. The paperwork requirements and bureaucracy soak up a quarter of a doctor’s time — time that could be better used to see more patients and improve health outcomes.

“All we would be doing differently is better using the money for health care versus administration,” Georgen said.

If voters give a thumbs up to Initiative 1600, the law would create a trust into which money to pay for health care would flow. The money would come from four main sources, including a 1 percent income tax, an 8.5 percent capital gains tax, an 8.5 percent payroll tax and a monthly premium ranging between $0 and $200.

Local income taxes were banned by the state legislature in the 1980s, and attempts by Gov. Jay Inslee to champion a capital gains tax have so far been rebuffed.

The plan also requires the governor and health care authority to seek waivers from the federal government to integrate publicly funded health programs such as Medicare and Medicaid, federal programs for people 65 years old and older and low-income people, respectively. The Trump administration is under no obligation to grant those waivers.

Georgen acknowledges the challenges but says that the trust can continue to operate and contract for benefits while federal negotiations take place.

“We can’t predict how long it would take,” she said.

The benefits packages offered under the proposal are rich, including vision and dental, and Whole Washington guarantees that low-income patients won’t pay anything out of pocket when they visit their health care provider. Higher income patients could pay an annual maximum of $250 for prescriptions, Georgen wrote in an e-mail.

Although Whole Washington is confident that its plan will work, a 2010 attempt in Vermont is a cautionary tale.

State-based single-payer systems may run into significant funding challenges, said Sara Collins, Vice president of Health Care Coverage and Access at The Commonwealth Fund.

Collins points to the experience of Vermont, home of single-payer proponent Sen. Bernie Sanders.

The Vermont legislature passed a bill to implement a single-payer system in 2010, but the experiment folded by 2014, sunk under the weight of expensive taxes.

“Vermont’s single payer ultimately failed because they couldn’t work out how the costs were going to be controlled and paid for,” Collins said. “The first big issue was the increase in taxes to support it, and the concern over how much that was going to go up every year.

“There needed to be a pretty strong cost control component,” Collins said.

It’s hard to do that in one state, which lacks the purchasing power of an entire country, unlike single-payer systems in other Western countries. Whole Washington proponents say that they will attempt to negotiate with pharmaceutical companies to bring down the high drug prices that contribute to the overall cost of health care.

Another critical component is buy-in from the federal government. Vermont didn’t have backing from the Obama administration, which was focused on defending President Barack Obama’s legacy-defining effort to extend health care access to the country, Collins said.

While the ACA is more stable — and vastly more popular — today than it was in 2011 when Vermont was pushing for federal help, the current administration hasn’t shown itself to be a fan of government-operated health care.

Despite the challenges, there is a feeling on the political left that single-payer health care, be it Whole Washington or a national Medicare for All program, is achievable, if difficult.

California has been working on a single-payer system for several years, but the bill stalled in 2017 after news that it would cost as much as $400 billion, double the state’s entire budget. While $200 billion of that would come from existing state and federal spending, the other half would have to be generated out of new taxation.

It’s unclear how well that effort is going. Scholars from the University of California at San Francisco, a school renowned for its medical program, drafted a paper examining early steps the state could take to transition to single-payer, but stopped short of saying it was a good idea.

Approximately 93 percent of Californians get coverage through Medicaid, Medicare, employer-sponsored insurance and the exchange, they wrote.

“Transitioning the vast majority of Californians into a new system of coverage, which does not have an established track record in the state, involves uncertainty and some risk,” the paper reads. In the interim, the authors suggested changes to increase coverage and improve equity, quality and efficiency that also laid groundwork for an eventual shift to unified health care financing.

In Washington, the I-600 crew is going full speed ahead.

They need to gather the 260,000 valid signatures by July 6 to get the measure on the ballot in November, Georgen said, and the work of volunteer signature gatherers has proven the hunger for a policy shift such as this one.

“At least in my opinion, universal health care for the U.S. is inevitable,” Georgen said. “It’s just a matter of time when we get there.”

Ashley Archibald is a Staff Reporter covering local government, policy and equity. Have a story idea? She can be can reached at ashleya (at) realchangenews (dot) org. Follow Ashley on Twitter @AshleyA_RC

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