There are formidable institutional obstacles to passing a single-payer health program in the United States. Advocates should consider incremental improvements that may better match legislative realities. There are three potential directions for incremental coverage policy.One possibility is to build on the successes of the Affordable Care Act; this might include rolling back regulatory changes, further incentivizing Medicaid expansion, enhancing coverage in the Affordable Care Act marketplaces, and imposing regulations on private employer-based insurance to ensure that all Americans have access to affordable coverage that provides adequate financial security. A second direction is to offer more publicly sponsored insurance options, which might involve offering a public option to those eligible for marketplace coverage, creating a Medicare or Medicaid buy-in program, lowering the eligibility age for Medicare, or developing a public plan that serves as a default for those who do not choose to buy alternative private coverage. A third direction is to build on federalism, offering states incentives to expand coverage.Federal and state legislators could also consider incremental cost-containment steps, such as rate setting.
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