States hold four distinct options for public health care, and almost every American debate about “the public option” or “single payer” collapses them into a single blur. This article separates them: regulated private carrier programs, publicly owned insurers, single payer for core coverage, and public payment combined with public delivery. The four differ enormously in what they deliver, and they form an ascending sequence rather than rival destinations, because each stage makes the next one easier to reach. Along the way I’ll answer the standard objections, because each one fails on the law, the economics, or the historical record. I’ll tell you which model I personally favor when we get there, but promoting it is not the purpose of this article. The purpose is to show you the full range of options, because a reader who knows the whole map organizes better and gets fooled less. I would be thrilled with any of the models above the first category, and thrilled most of all to watch a state simply enact full single payer.
The stakes of the classification are practical. Enormous volunteer energy currently goes toward fighting a captured federal system on terrain that system controls: gerrymandered maps, a bought Supreme Court, a Senate that overweights empty land, and an Electoral College that does the same. Meanwhile Democrats hold complete governing control in states covering more than 100 million people, and that control sits largely unused. Health care is the clearest place to use it, and using it well requires knowing exactly what the options are.
The first category is regulated private carrier programs, and several states market these as public options despite the absence of any public insurer. Washington’s Cascade Care, the Colorado Option, and Nevada’s program all follow the same design: the state standardizes benefit packages and caps provider reimbursement, and private carriers sell and underwrite the plans. The insurer remains private, the risk remains private, and the margin remains private. These programs have produced modest premium effects, and those modest results now circulate as evidence that public health coverage fails. The evidence proves no such thing, because no public coverage was ever created.
The second category is a publicly owned insurer competing for voluntary enrollment: the state charters its own insurance company, bears the risk itself, and competes with private carriers for members. A state creates such an enterprise through ordinary legislation, and the precedent is more than a century old. North Dakota chartered the Bank of North Dakota in 1919, and it remains the country’s only state-owned general-service bank, profitable every year, never bailed out, and a steady contributor to the state’s general fund. The same chartering power applies to insurance, and this model is my personal favorite, for reasons of implementation rather than destination: it generates its own revenue, carries little to no tax burden, and, run well, it recruits its own political support, because every member who receives quality service becomes an advocate for expansion. The model already operates successfully in American health care. MetroPlusHealth, a subsidiary of NYC Health + Hospitals, serves nearly 700,000 members as a public insurer competing directly with private carriers. Its Gold Plan covers New York City employees, retirees, and their families with a $0-premium, $0-deductible basic option, and the city opened it to the entire municipal workforce in 2015 as a deliberate growth strategy for the public system. The replication path for any state follows directly. Begin with all public employees and their families, funded by redirecting the money the state already spends on their coverage, which gives the plan a large, stable membership and revenue from the first day without one new tax. Open enrollment to the general public afterward, with income-scaled premiums paid directly to the plan. The sequencing answers the standard actuarial objection that voluntary public plans attract the sick first: the public-employee membership arrives before open enrollment, so the plan holds a broad risk pool before the early adopters join.
The third category is single payer for core coverage: one public payer covers every resident’s core care. This category is what state-level Medicare for All bills propose, including the New York Health Act, CalCare in California, and Whole Washington’s Health Trust. Here the most common American belief about single payer is simply false. Nearly every single-payer country keeps private insurance. Canada allows supplemental coverage for prescription drugs, dental, and vision, and most Canadians carry it. Australia operates a full parallel private hospital system alongside its public Medicare. Private insurance operates alongside the National Health Service in Britain. Single payer describes who pays for the core benefit package, never a ban on private coverage. Which reveals how thin the wall between category two and category three actually is: a publicly owned insurer that keeps growing until private core coverage becomes redundant has become single payer in function, with no conversion date and no abolition of anything.
The fourth category adds public delivery to public payment: the state owns and operates facilities in addition to paying for care. American governments already run hospitals everywhere. NYC Health + Hospitals operates the largest public system in the country, county governments run major systems like Harris Health in Houston and Cook County Health in Chicago, state universities own academic medical centers, and Washington alone has dozens of public hospital districts operating today. This category expands that footprint substantially, and the expansion attacks costs at their source. Private hospital prices run roughly double what Medicare pays for identical services, hospital pricing is the largest single driver of American cost excess, and a facility the state owns has no monopoly margin to charge, because the price becomes an internal budget line rather than a negotiation the hospital wins. Public delivery also protects the payment system itself: a public plan that depends entirely on private hospitals can be squeezed by the rates those hospitals demand, while a state with its own capacity negotiates from strength or bypasses the negotiation entirely. And where private operators close rural hospitals and maternity wards when the margins fail, public facilities answer to need, which is why Washington’s hospital districts exist in the first place.
Now let’s explore some of the objections.
“No state has the funds to support universal health care.”
Every single one of them has the funds, and dozens of smaller economies prove it. New Zealand covers everyone on a gross domestic product smaller than Louisiana’s. Denmark’s economy is roughly half the size of Washington state’s. Costa Rica achieves universal coverage and life expectancy exceeding ours on about $70 billion of total output. The United States spent $15,474 per person on health care in 2024, 18 percent of the entire economy, while every universal system on Earth spends a fraction of that and delivers better outcomes. American states hold no shortage of money. They overpay, by roughly double, for worse results.
“No state has ever successfully implemented one.”
Saskatchewan, July 1, 1962. A farm province of under a million people built single-payer alone, survived a 23-day doctors’ strike backed by the American Medical Association, and operated without federal funding until 1968. The model worked so well that within 10 years every province in Canada had copied it. Taiwan repeated the feat at national scale: its legislature passed the bill in July 1994 and launched the system in March 1995, and within a year the 41 percent of the population that had been uninsured reached the same utilization rates as the previously insured. Coverage today stands at 99.9 percent. And for category two, New York City’s publicly owned insurer has competed successfully for three decades. The proof of concept exists at every stage of the sequence.
“Federal law stops states from regulating or taxing employer health plans.”
The Employee Retirement Income Security Act blocks states from regulating employer benefit plans, and the objection requires treating that partial restriction as a total one. It does not block states from taxing employers and covering residents, and a state system does the second thing, not the first. The Supreme Court drew this exact line unanimously in New York State Conference of Blue Cross v. Travelers (1995): a state law of general applicability survives even when it raises costs for ERISA plans, because it regulates no plan. The Court applied the same rule unanimously in De Buono v. NYSA-ILA (1997), upholding a state tax on an ERISA plan’s own hospitals, and again unanimously in Rutledge v. PCMA (2020). Three unanimous decisions across 25 years. Under a state system, employers keep their ERISA plans untouched; the plans simply become redundant because every resident is already covered. And a publicly owned insurer raises no ERISA question at all, since it competes for enrollment like any other carrier.
“Redirecting federal funds requires complex federal waivers.”
Waivers are required only for one specific design: merging Medicare and Medicaid dollars into a single state pool. That design is optional. A state can cover every resident from its own revenue while Medicare and Medicaid keep operating exactly as they do today, and the waiver requirement never triggers. No federal permission is needed to insure your own residents. And even for a state that wanted the merged pool, waivers are routine machinery: dozens of Section 1115 waivers govern huge portions of state Medicaid programs right now.
“Funding it requires massive tax increases.”
This objection counts the new payment and hides the eliminated one. Employer family coverage now averages $26,993 a year in premiums, with workers paying $6,850 of that directly out of paychecks before deductibles and copays even begin. That money is already effectively mandatory, priced by entities the payer does not control. The replacement contribution goes to an administrator running roughly 2 percent overhead instead of private insurers running 12 to 18 percent, so it comes in lower for most households. A payment that replaces a larger payment is not an increase. The contribution also doesn’t have to be structured as a tax at all: income-scaled premiums paid directly to the plan are established practice in Medicare Part B, in German sickness funds, and in British Columbia for decades, and a category-two insurer runs entirely on premium revenue from the start. The “political backlash” variant of this objection depends on the tax-increase claim being true. Most households would pay less for broader coverage, and voters reward the people who deliver that.
“Sáenz v. Roe means a state would face an unmanageable influx of out-of-state patients.”
Sáenz struck down paying new residents lower benefits than established ones. Bona fide residency requirements are untouched, which is why every state uses them today for Medicaid and in-state tuition. And the feared influx has never materialized anywhere: universal coverage has rolled out region by region across the world, from Saskatchewan to Massachusetts in 2006, and no system has collapsed from this mechanism. The research explains why. People move for jobs, family, and housing, and the sick are the least mobile population there is. Anyone who does relocate becomes a working resident paying in, which is exactly the in-migration every state competes to attract.
So the law permits every category, the money already exists, and working models operate today at every stage. What remains is organizing, and the organizing capacity already exists too. Indivisible chapters alone number in the thousands, and none of them would need to abandon their existing work. If the chapters in a single trifecta state simply added state-level public health coverage to their priorities and applied the pressure they already know how to apply, that state would have universal coverage in under two years. In Washington, Whole Washington has drafted the Washington Health Trust and carried companion bills in both chambers with a record number of co-sponsors. Similar campaigns have run in California, New York, and New Mexico.
Fifty years of health care debate has taught Americans to treat universal coverage as a federal responsibility, which means waiting on the one level of government where we have the least influence, fewest accountability mechanisms, and where oligarchs exercise the most control. The taxonomy above offers far more effective options in those four models, three of them proven at scale, and all of them within the existing legal and fiscal power of the states, and each one a foundation for the next. A single state that acts settles the argument for all fifty, the way Saskatchewan settled it for Canada.
We can get it done, it’s just a matter of educating others, activating ourselves, recruiting more folks to do the same, and repeating that process so that our preferred outcome becomes inevitable.
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Call to Action
Every state has the money and the legal authority to guarantee health care to every resident. Pick whichever model above you want your state to pursue, then bring it to any of these, or all of them:
Your state legislators. Find yours at Open States. Ask them to sponsor or support legislation creating the model you’ve chosen.
Your county Democratic party. Search your county’s name plus “Democratic party.” Ask them to pass a resolution endorsing it.
An existing campaign in your state, like Whole Washington. Ask how to volunteer.
Organizations where you already have a voice: your union, your Indivisible chapter, your legislative district organization. Ask them to adopt it as a priority.
In your own words: who you are, where you live, why you care, what you want them to do.
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I'm retired Navy. I've had universal healthcare my entire adult life. There's no reason we can't all have the same. We don't because voters don't believe it's possible and politicians don't have what it takes to deliver. It has nothing to do with money. It has everything to do with valuing human beings.
I fear the oppositiion to universal Health Care is not the people, it is the Republican Party that have been bought by the special interests that profit from reactive medicine rather than Unifersal Health Care services that actually reduce illness. For a snarky alalogy, Towtrucks do not make money from good tires and brakes. Should towtruck companies be allowed to buy policies that create road standards and services? Big Pharma has bought Congress.