The state of single payer in the states: Saskatchewan a model

By Joan McCarterFollow
Daily Kos
October 4, 2011

Last week, Daily Kos asked Governor Brian Schweitzer about his plan to pursue a single payer health system for the state, modeled on the system pioneered by Saskatchewan Province in Canada.

"Montana has a population of 990,000 people," he explains. "Saskatchewan has a population of 1,050,000. Their average age is about the same average age of Montana. They're about 10 percent Indian, we're about 7 and a half percent Indian. The other ethnic groups—they're a mirror image of us.... So we have the same ethnic population, we're farmers, we're loggers, we're miners, we're oil developers.... They, in Saskatchewan, live two years longer and have lower infant mortality."[...] "We have an $8 billion health care industry in Montana right now, and 50 percent of it, or $4 billion, is coming directly from the federal government," he continued. "That may be enough so that we can get the rest of Montana in it. We turn to the rest of Montana and say to them we've got this $4 billion, and we're taking care of all these people, and now we've run the rates and if you want to pay into this system, here's how much it's going to be. If you don't want to buy into that system, you don't have to."

"If you want to pay twice as much for Blue Cross and Blue Shield and have their accountants lie to you," the governor said, "you just stay right where you're at. But I think they'll knock our door down."

Schweitzer's plan requires waivers from the federal government primarily for Medicaid, but potentially for all federal health systems. Schweitzer wants to include Medicare, Medicaid, Indian Health Services, SCHIP, VA—all federal health systems—to pool that $4 billion to set up a public option. He'd like to implement this program as soon as possible, so he is not waiting to see what the outcome of the various legal challenges to the Affordable Care Act will be, or for the provision of the law that allows states to apply for waivers to set up their own systems rather than the standard ACA exchange. Since Montana's Republican-controlled legislature refused to pass legislation to set up the exchange, as required by the law, Schweitzer's plan could be the kernel of a federal-state partnership under the law.

Two other states have innovative single-payer plans that are well-developed, while a handful are in the "still talking about it" stage, and one has abandoned its efforts. Vermont and California are the furthest along, and Connecticut has backed off a public option plan that had been in the works for years.

Vermont has established Green Mountain Care, a bill actually signed into law. There are still critical details, like how the program would be financed, to be worked out. This is where the Schweitzer model might come into play, and could be a sort of ideological reversal of the Republican answer for all programs—a block grant. Using all federal health care dollars spent in Vermont, or Montana, as a lump sum to finance a public health system, with the option for people with private insurance to buy in, is a smart solution.

They're looking at using the funds offered in the ACA to assist states in building the health insurance exchanges. Vermont is seeking a waiver to pursue the single payer system and not have to run a separate exchange. As the law stands now, they can't get that waiver until 2017. Democrats in both chambers of Congress have introduced legislation to move that date up to 2014, legislation which President Obama supports, and in fact has included in his jobs plan. For Vermont, the big question is whether there's any leeway for the administration to grant waivers ahead of what's allowed in the ACA for the system to be implemented. Vermont's success in this, in turn, could help clear a path for Montana.

California has made substantial legislative progress toward setting up its own single payer program, with a block of "two-year" bills that will both ready the state for the 2014 implementation of the ACA, and lay groundwork for a single payer system, a bill which is also slated to be considered next session.