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Since Bernie Sanders made it a cornerstone of his 2016 presidential run, Medicare for All has become an increasingly popular and obvious demand. The system, which works by eliminating the private insurance market and relying on the government as the sole payer of health care costs, has been used by many other countries for decades. Americans, by contrast, pay costly monthly premiums to private insurance companies and still can’t even use their benefits because of outrageously high deductibles. And if you’re fortunate enough to receive decent health insurance through your employer, you are left vulnerable to an otherwise hostile workplace, since keeping your health care depends on keeping your boss happy. The failure of Obamacare to rein in costs and reliably expand coverage has led people to a logical conclusion: why not just get rid of private insurance altogether? Unfortunately, under the present administration, a federal improved Medicare for All program is unattainable — just recently, President Trump felt compelled to attack Medicare for All in a USA Today op-ed. As a result, many have retreated to state legislation. But state single-payer efforts face a number of major challenges. One would be navigating the existing, fragmented federal health care system. To streamline this process, Rep. Pramila Jayapal, D-WA, has put forward a bill that would make it easier for any state to request permission to opt out of programs like Medicare and Medicaid and receive federal waivers in their place — a prerequisite for any state single-payer health care program — via a single application to the US Secretary of Health and Human Services. While Jayapal’s plan would put some blue-state voters half a step closer to their own state health programs, it does very little to require that those programs do anything more than further balkanize our existing system. The most glaring issue with her plan is that it has few minimum requirements for what a state single-payer plan would need to provide in order to allow federal funds to be redirected to state health plans. After the fanfare around and then failure of Obamacare, one would hope that Democrats had seen the problem with tinkering around the edges of American health care, trying to preempt objections to a single-payer system by being “reasonable.” Jayapal should be commended for trying to bring us closer to winning Medicare for All, but she’s put forward a bill that repeats many of the same mistakes. Especially when compared to the Medicare for All legislation she is already a co-sponsor of, it’s hard to explain why this overly complicated and much less politically inspiring bill even exists.

A Day Late and a Dollar Short To get into the problems with Jayapal’s bill, we have to get a bit wonky. Unlike the existing House and Senate Medicare for All bills, which would both eliminate the private insurance industry and establish a true improved Medicare for All program, Jayapal’s bill does not require that states seeking waivers prohibit private health insurance or the private administration of public health plans. In fact, she explicitly allows for states to continue contracting out the administration of their health plans to private corporations. A major benefit that comes with implementing public health insurance is that it cuts out the parasitic health insurance industry which pockets 30 cents of every dollar Americans spend on health care; Jayapal’s bill would allow those corporations to continue extorting the public, now from behind the cover of a purportedly public health program. In effect, Jayapal’s bill only gets at the symptom — lack of universal coverage — while the Medicare for All bills in the House and Senate tackle the cause: private insurance. If the bill hopes to address the root of the problem, it would include a requirement that any state seeking exemptions would prohibit competing commercial health insurance and contracting out state responsibilities to private corporations. Under our current system of private insurance, an American making around $50,000 spends a little over 9 percent of their income on health care, about $4,500 per year. That’s $4,500 paid into a system where you still have to worry about going to the wrong hospital, finding a needed specialist in network, or debating whether your back pain is really bad enough for that office visit co-pay. Any solution to our present crisis needs to address this problem. Unfortunately, the only spending requirement in Jayapal’s bill is that no more than 5 percent of the population spend more than 10 percent of their gross adjusted income on health care. But this means very little when you consider that the spending cap is effectively the same percentage that Americans are already paying today. If the cost to the individual is going to be roughly the same, we might at least expect better benefits under a state plan. Once again though, Jayapal’s bill provides hardly any minimum requirements. The only baseline states must ensure is that people receive health coverage at least as comprehensive as the coverage they would have otherwise received under existing federal programs like Medicare and Medicaid. That means that anyone who doesn’t already qualify for federal benefits — a majority of Americans — would have no guaranteed state benefits. States could of course choose to provide excellent coverage to their residents; they could just as easily provide next to nothing. The bill’s meager requirement, stipulating that no less than 95 percent of those covered by a state plan must be protected under the spending cap, raises a troubling question: what about the other 5 percent? If passed, her plan would allow them to continue being crushed under life shattering medical debt. Even if the spending cap were extended to 99 percent of the country, it would still be qualitatively different — and more importantly, weaker — than a universal program. This is because public programs that aren’t truly universal open themselves up to political attacks. If even a fraction of a percent of the population were left to the whims of the market, that would mean some people would still suffer under the for-profit health care system. But now rather than directing their anger about that suffering at insurance companies, those not covered could credibly point at the public program as the source of their misery. We would be giving capitalists a weakness they would be all too happy to exploit in an attempt to bring down the entire project. Doctor and single-payer advocate Adam Gaffney recently outlined four core principles of a true universal health care program: The World Health Organization, for instance, sketches out the three dimensions of universal coverage: the percentage of the population “covered,” the degree of cost-sharing (that is, out-of-pocket payments like co-pays or deductibles), and finally, the comprehensiveness of benefits. To these I would add a fourth element, of equity: to what extent does the nation offer a similar level of access to providers, hospitals, and other healthcare goods and services to all, regardless of economic means? While Jayapal’s bill does attempt to fulfill the first requirement by asking states to reach 100 percent coverage within ten years, it has woefully insufficient guidelines for cost-sharing, benefits, and equality of care. Compare all this with Bernie Sanders’s plan, which proposes universal, comprehensive coverage with no financial barriers to care. These shortcomings make it difficult to accept that, whatever her intentions, Jayapal’s bill would be a step forward in the fight for universal health care. Supporters will almost certainly point out that her bill is only meant to streamline the process of establishing state health care programs. The real test will be whether individual states actually implement strong universal programs. But that only leads us to the final worry we should have about her plan.