National Nurses United

12 N A T I O N A L N U R S E W W W . N A T I O N A L N U R S E S U N I T E D . O R G M A R C H 2 0 1 4 S o here we are. Four years after Congress passed and President Obama signed the Patient Protection and Affordable Care Act of 2010, it is clearer than ever that the law, even after full implementation, falls far short of the ideal of covering every resident of the United States and providing equal access to quality, affordable care. Some 18 states have set up health insurance exchanges, others are leaving it to the federal government. Only about half of the states have chosen to participate in an expansion of Medicaid, and many have refused to—despite high per capita levels of poverty in those states. According to most reliable estimates, more than 30 million Americans will remain completely uninsured under the PPACA, and many millions more will be underinsured as they enroll in lower-cost plans that leave them vulnerable to high deductibles and other out-of-pocket costs. Single-payer healthcare advocates find all of this complexity and lack of access unacceptable. Because any major health reform at the national level is not likely, individual states are pressing for- ward with plans to set up and implement their own state-based, single-payer systems. The PPACA includes provisions, notably Section 1332, that allow states in 2017 to start "innovating" in covering their residents. That section of the law would grant waivers for state-based plans that have benefits at least as generous as those available as "essential benefits" under the PPACA and provides that coverage to at least as many individuals at a cost that is equal to or less than that paid on the exchanges. Single-payer plans certainly meet or exceed those requirements, so many states have active political and social movements pressing for- ward to achieve their goal. As of last count, at least 22 states are cur- rent involved in some level of single-payer activity. While a few states have had state-based single-payer legislation introduced or passed in recent years, others are still building the grassroots support for single- payer reform that will likely grow as the deficiencies of the PPACA grow increasingly apparent to more individuals and businesses. It's instructive to note that this state-by-state adoption of single- payer is actually how Canada won its Medicare-for-all system, which was first enacted in the provinces of Saskatchewan and Alberta. It's also how movements for many of the United States' most significant political reforms, such as the right to vote for women, built the momentum needed for federal action, so there is much historical precedent for taking this approach. Vermont the state leading the single-payer charge in the post-PPACA era is currently Vermont. In 2011, the Vermont Legislature passed its bill to establish Green Mountain Care, and Gov. Peter Shumlin Domino Effect Single-payer advocates play a state-by- s

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