As Congress decides whether to repeal a key provision of the Affordable Care Act, a Maine-based task force set to meet for the first time next week will be studying state-based fixes to the health care system. Included in the discussion would be long-shot proposals to establish a single-payer system in Maine.

The Health Care Coverage Task Force – created by the Legislature after a hearing on a single-payer bill that failed earlier this year – will meet Wednesday in Augusta to begin a wide-ranging discussion on health care. The task force includes residents, a bipartisan mix of eight lawmakers, and representatives from health care groups, hospitals, the insurance industry, and small and large employers.

Sen. Geoff Gratwick, D-Bangor

Sen. Geoff Gratwick, D-Bangor, a physician who is on the task force, said that although he supports single-payer in theory, he’s looking for practical solutions that can be supported by Republicans, Democrats, patients, hospitals and health care professionals.

“No health care reform is going to work unless we bring everyone to the table,” Gratwick said.

Democrats tend to support single-payer, but Republicans are usually opposed.

While many European countries and Canada have established universal health care systems, the United States created the Affordable Care Act under then-President Barack Obama, reforming the existing system rather than creating a single-payer version. No state has adopted a single-payer system despite several attempts to do so.


Single-payer means that a single entity – usually the federal government – is responsible for paying health care providers such as doctors and hospitals. Out-of-pocket costs for individuals go down, but taxes are increased to compensate. The U.S. has elements of a single-payer system in the Medicare and Medicaid systems for seniors, the disabled and low-income populations. The ACA reduced the number of uninsured by expanding Medicaid and offering subsidized insurance to working-class and middle-income families that didn’t have employer-based insurance.


Since congressional Democrats and Obama muscled the ACA through Congress on a party-line vote in 2010, many Republicans have argued that it doesn’t work well and have tried to dismantle it.

President Trump and congressional Republicans came within one vote of repealing the ACA this summer – with Republican Sen. Susan Collins of Maine a key “no” vote – and are trying to weaken the ACA in a number of ways, including by repealing the individual mandate in the pending tax reform bill.

Repealing the individual mandate – which requires people who can’t get insurance through an employer to purchase coverage or pay a penalty – would result in 13 million fewer Americans with health care coverage, the Congressional Budget Office estimates. The Trump administration also has cut ACA advertising and outreach budgets and slashed the enrollment period from 12 weeks to six.

Meanwhile, as Congress and the Trump administration consider ways to undermine the ACA, California is exploring adoption of a single-payer system. A bill to create single-payer stalled in the California Legislature this year, but Lt. Gov. Gavin Newsom is a strong supporter of universal health care and he is considered a leading Democratic candidate for governor next year.


However, other efforts to create state-based single-payer systems have collapsed – including in Vermont in 2015, Oregon in 2002, Colorado in 2016 and California in 1994. Voters soundly rejected single-payer ballot initiatives in Oregon, Colorado and California.

John McDonough, professor of the practice of public health at Harvard University, said single-payer system proposals in the United States have failed when details start emerging.

“As much as people are attracted to the idea, it has always fallen apart when you get to the issue of finance. How are we going to pay for it? Then the exuberant support fades, people’s fears take over and it falls apart,” McDonough said.


He said the referendums in Oregon, Colorado and California started with promising levels of public support before failing at the polls, with less than 30 percent of voters voting “yes.”

But Delene Perley, education and communications chair for Maine AllCare, a group that advocates for single-payer, said she looks to Canada, which started in the provinces before becoming a countrywide system in the 1980s.


“If we can’t get universal health care done nationally, we can start in the states,” Perley said. She said she’s also encouraged by the Nov. 7 vote in Maine to expand Medicaid, which passed with 59 percent of the vote. Perley believes Maine AllCare eventually will launch a referendum drive.

“It’s headed that way,” she said. “That Medicaid vote was a good sign. People want health care that they can access and afford.”

Perley doesn’t hold out much hope that the Maine task force will recommend a single-payer system, but “it’s a start. It’s opening the discussion,” she said.

McDonough said there are many reforms that states can approve to improve health care affordability without going to a single-payer system, such as a robust reinsurance program in Alaska that allows people to “buy into” Medicare or Medicaid, or simply offering more generous subsidies on the ACA’s individual market.

For instance, the Massachusetts state government approved a system similar to the ACA in the 2000s under Republican Gov. Mitt Romney that offered enrollees more generous subsidies than what was later approved under the ACA. When the ACA’s individual market started in 2013, Massachusetts continued the generous subsidies – supplementing federal ACA funding with state dollars – so that enrollees wouldn’t see their health care costs go up, McDonough said.

He said the more generous system has led to Massachusetts having the lowest uninsured rate in the nation, at 2.8 percent.


McDonough said there’s nothing stopping any state from making reforms similar to the ones in Massachusetts, which would lower health insurance costs and make coverage more affordable for those buying on the individual market.

“You can go for the so-called ‘perfect system’ in single-payer, and end up with nothing,” he said. “Or you can make these other, more incremental, reforms.”

Joe Lawlor can be contacted at 791-6376 or at:

Twitter: joelawlorph

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