If the Supreme Court strikes down the individual mandate on Thursday, states are left with a vexing question: What next?

A liberal coalition in California wants to make the answer single-payer. The Courage Campaign, a Los Angeles-based alliance of progressive groups, has an advocacy plan ready to roll out should any part of the law fall.

Next exit: Single-payer? (Ken Lund | Flickr)


"In the state of California we think we have a unique opportunity," says Paul Song, a physician who sits on the Courage Campaign's board. "Being the eighth-largest economy, and a state that has aggressively implemented the law, it could allow us to bring forward a better law."

If the health reform law falls, Courage Campaign will blast out its single-payer plan to its 750,000 supporters. If it gets upheld, however, no e-mails go out.

Advocates outside of California have similar plans: Here in Washington, the Progressive Change Campaign Committee plans to hold a Thursday press conference at the Supreme Court advocating for Medicare for all, regardless of the decision. About a dozen members of Congress are expected to attend.

“If the Supreme Court rules against Obamacare, we have to have a substantive policy and political response — in my view, that’s Medicare for All,” Rep. Pete Welch (D-Vt.) tells my colleague Greg Sargent. “Medicare is very popular. People understand it.”

While a single-payer system may be a pipe dream in Washington—almost certain to stall in Congress—that's not necessarily the case in California.

The state legislature twice passed single-payer bills, in 2006 and 2008, subsequently vetoed by then-Gov. Arnold Schwarzenegger. Now Democrats control the governor's seat - and think they may have found the "perfect storm" to move a single-payer bill.

Here's how the thinking goes: If the individual mandate falls, but the rest of the law stands, California still expects to receive a big pile of money to expand insurance coverage. The state has the highest number of uninsured people anywhere, meaning it will get one of the biggest funding boosts. For the Medicaid expansion alone, between 2014 and 2019, the state expects to receive $55 billion.

If California got the necessary waivers from the Obama administration, it could pool those dollars with existing funds to lay a foundation for a single-payer health care system. It's an approach relatively similar to the one that Vermont is now pursuing.

"In the past, its been hard to approve this with the economic climate," Song says. "The federal funding could make this work."

That's the optimistic outlook, at least. Song admits there are a lot of hurdles in the way. For one thing, the waivers that the state wants do not exist right now. They're a part of Rep. Jim McDermott's (D-Wash.) legislation that would allow states to combine all their Medicare, Medicaid and other, federal health dollars into a single-payer system. That's unlikely to move through a Republican Congress.

The state could, however, use the law's existing state innovation waivers—the ones that start in 2017—to do a single-payer system for everyone except Medicare patients. This, again, is how Vermont has pursued single-payer: leaving Medicare out.

"We could use universal coverage as a step to single-payer," Song says.

Then, there are the local politics: A single-payer bill did come up in the California Senate this year, but fell two votes shy of passing out of the Democrat-controlled committee.

This new campaign, if it launches on Thursday, would focus a lot on lobbying those California state senators to rethink their votes. It would also explore the possibility of a ballot initiative on the issue.