Volume 29

Health Injustice in the Laboratories of Democracy

by Elenore Wade

A growing majority of Americans support the implementation of a national single-payer healthcare program, also known as Medicare for All, which would shift payments for healthcare services to a single public payer and provide care
based on need rather than ability to pay. However, legislators, scholars, and advocates have suggested state governments rather than the federal government should take the lead by implementing state-based single-payer programs. Dozens of single-payer proposals have been introduced in state legislatures across the country, and proposed legislation in Congress would remove the federal roadblocks to state-based single-payer’s implementation. Proponents of state-based single-payer rely on the conventional wisdom that states—as the storied “laboratories of democracy”—can prove the concept of single-payer to other states, who will adopt it in time.

But, in taking the “laboratories of democracy” theory at face value, advocates of state-based single-payer ignore a number of realities fatal to the assumption that universal healthcare will come from the states. This Article argues state-based single-payer is not a stepping stone to health justice or the implementation of national single-payer and that it is, rather, a stumbling block that will worsen health inequities in the United States and ultimately make the implementation of a national single-payer system even less likely than it is now. In order to demonstrate this, I analyze the history of state government experimentation in healthcare to conclude the laboratories of democracy theory has been tested in the healthcare domain and failed, harming the nation’s most vulnerable and historically oppressed people. Using the example of the Affordable Care Act Medicaid expansion, I discuss the historic and present antidemocratic state government resistance to programs that promote health justice, particularly when those programs would increase healthcare access for poor people and people of color. Furthermore, I employ a political theory analysis to conclude state-based single-payer is not an acceptable policy for the federal government to promote under a health justice framework. This is because the implementation of state-specific single-payer programs will worsen health disparities by weakening the bargaining power of existing federal programs such as Medicare and Medicaid and by fracturing a growing constituency in favor of single-payer, chilling popular momentum toward a national single-payer program.

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