Maryland, the  one state is where a combination of fewer institutional barriers and existing health care structures could make health-care-for-all an achievable reality.   This opportunity us built on unique idea, called “all payer.”

Maryland is the only state to already hold a Medicare waiver incorporate programs like Medicare into a state-run program,.  Maryland is also the only state in America where all hospitals must charge the same rate for services to patients, regardless of what insurance they carry. There’s some variance between hospitals, but every patient in a particular hospital pays the same. Other states experience huge, seemingly random differences in hospital costs, depending on the insurer (or lack thereof).  Maryland has a Health Services Cost Review Commission that sets hospital reimbursement rates. The all-payer system has  worked, creating the lowest rate of growth in hospital costs in America.

Under all payer, a hospital’s global budget doesn’t change based on the number of admissions.  This creates hospital incentives toward better outcomes. “It makes the health system focused on keeping people healthy rather than just treating illnesses,” said Vincent DeMarco, president of the Maryland Citizen’s Health Initiative, a state advocacy group. That includes increased preventive treatment, using case managers to connect patients to primary care, eliminating unnecessary tests, and encouraging good health outside the hospital walls.  Three years into global budgeting, hospital revenue growth is well below counterparts nationwide, or the growth of Maryland’s economy. Plus, state hospitals have saved $429 million for Medicare, more in three years than it targeted for five. Most important, every state hospital (all of which are nonprofit) and every insurer in Maryland are on board with the system.

Maryland’s model follows the precedent of France, Germany, Japan, Switzerland, and The Netherlands.   These states use all-payer rate setting as the basis for their universal health care systems. and control costs far better than America’s fragmented system even when the payer is private and, presumably profitable.  Even here in the USA, Vermont moved to an all-payer accountable care organization after the state’s effort at single payer failed.