If single-payer health care is ever to become a reality in the United States, it will very likely be pioneered by a state government, much like Canada’s single-payer system was first adopted in the provinces. Canada’s system operates more like U.S. Medicaid — financed nationally but administered largely by the provinces — than U.S. Medicare. This article describes three basic strategies progressive U.S. state governments are exploring for achieving universal access to high-quality health care and better health outcomes for their residents. First, maximizing eligibility for the existing Medicaid program using matching federal funds. Second, taking up the mantle of Obamacare by adopting state-level replacements for provisions that federal lawmakers repeal, subsidizing and regulating the price of private insurance, and making more affordable coverage available for purchase on state-run health insurance exchanges. Third, I focus particularly on the efforts of states to succeed where federal reformers have failed by adopting a state-level public option or single-payer health care system. Although state-level public-option and single-payer health plans face significant obstacles, they are more feasible than federal reforms. Moreover, I argue, state-level single-payer health care may be preferable from a health justice perspective because it holds greater promise for integrating health care, public health, and social safety net program goals to achieve better health for all. State lawmakers must proceed cautiously, however, particularly with respect to ensuring that people entitled to traditional Medicaid benefits, which offer special coverage for special populations, continue to receive them. Additionally, state lawmakers should carefully assess the role that privatized public coverage currently plays in their health systems and what role, if any, it should play in public-option or single-payer reforms
