Why didn't Liberal states all have state run health care?

Question

For many years, there were attempts at making national health care coverage, which finally passed as the ACA.

The ACA ("Obamacare") was controversial vis a vis constitutionality (it won by a five-four margin at the Supreme Court for a different reason than that given by the White House legal team) and its general usefulness, with mostly Republicans opposing.

You could expect that most liberal states would have their own "state-wide" Healthcare exchanges when debate was stalled on a national level.

Yet, California and New York (which are, nationally, generally Democratic / Left leaning states) among others, didn't have them.

Why not?

Answer 1

when debate was stalled on a national level.

When was that? I'm going to assume that you mean Hillary Clinton's failed initiative in 1993. Note that this was followed by a big turn away from Democrats at both the national and state levels.

Source: https://www.washingtonpost.com/news/the-fix/wp/2015/09/11/49-charts-that-tell-the-partisan-history-of-state-legislatures/

Rather than being ready to start new liberal initiatives, even liberal states like Massachusetts and New York had Republican governors during this time period. William Weld, Mitt Romney, George Pataki, Arnold Schwarzenegger, etc.

Things flipped around in 2006 and 2008 before returning to form in 2010. And perhaps not coincidentally, it was around 2006 that Massachusetts passed health care reform. Vermont was working on a larger reform that was deemed too expensive to continue.

A side issue is that even Massachusetts' 2006 reform required federal assistance. So much of the health care budget is Medicaid, that they needed waivers to create their system. So they weren't exactly able to avoid federal involvement even then. It's not clear if a Democratic governor would have been able to get the same support as Mitt Romney did.

Source: http://byrondennis.typepad.com/masshealthstats/2011/09/what-is-the-romneycare-medicaid-waiver.html

Answer 2

It costs too much in taxes. Vermont had universal single-payer health care in 2011, but abandoned it in 2014.

https://en.wikipedia.org/wiki/Vermont_health_care_reform

Vermont Democrats abandoned their plan for universal health care, citing the taxes required of smaller businesses within the state.

As of April 2014, Vermont had yet to craft a bill that would address the $2 billion in extra spending necessary to fund the single-payer system.

Answer 3

It's too expensive.

It's generally too expensive for a state government to fund the insurance subsidies required to implement state run health care. The marginal revenue created by the mandates don't outweigh the cost of universal coverage including, in particular, the cost of covering pre-existing conditions.

If the subsidies aren't paid, the insurance companies will stop offering insurance in those states. On the other hand, if taxes are raised to try to fund the increase, then states begin to fear overtaxing their populations and seeing businesses and employers migrate to states with lower taxes and less regulation.

Unlike the federal government, states can not monetize their debt (i.e., print money AKA quantitative easing). Therefore, the economic obstacles to implementing a state run healthcare system have prevented adoption by even the most liberal states like California, New York and Hawaii.

It is worth noting, however, that although the obstacles were significant, they were not impossible to overcome in every case. For example, Massachusetts implemented a state run system under Mitt Romney's administration.