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?

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    An exchange is not very useful without subsidies and an individual mandate. Are you asking why they did not implement something like Obamacare on the state level?
    – Relaxed
    Commented Mar 10, 2016 at 8:16
  • 1
    @relaxed Yes. That is my question.
    – user7532
    Commented Mar 10, 2016 at 19:50
  • 7
    Obamacare was modeled on Romneycare in Massachusetts. An irony since Mitt Romney, who passed it as Governor of Massachusetts ran for President on a platform of repealing Obamacare. So at least one liberal state did have it before the ACA.
    – J Doe
    Commented Mar 10, 2016 at 20:50
  • Could you add citations? As far as I know, CA and NY do have exchanges. Or are you asking why they didn't create their own while ACA was being drafted? If so, I think the obvious answer is because the ACA was being drafted...they wanted to wait and join the ACA rather than go and reinvent their own wheel.
    – user1530
    Commented Mar 11, 2016 at 16:11
  • 2
    @blip The question is why CA and NY didn't have any comparable system in place prior to the ACA being drafted, like MA did.
    – Era
    Commented Mar 11, 2016 at 20:33

3 Answers 3


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

  • 1
    I'm not sure how this answers the question, "Why didn't Liberal states all have state run health care?" I see you're running with the assumption the OP made that there was a stall at the federal level, but limiting the answer to only that time period misses out on the time before (and a little after), and only to those states that were briefly republican governed. It doesn't seem like a complete explanation.
    – Adam Davis
    Commented Feb 15, 2018 at 19:23

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


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.

  • 2
    I think this answers the question as to why Vermont doesn't have a single payer system.
    – user1530
    Commented Feb 16, 2018 at 20:09

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.

  • 4
    The exception sort of discounts the rest of the answer. While there's no doubt it is expensive, it's certainly doable. For example, every province in Canada has done it.
    – user1530
    Commented Mar 2, 2017 at 3:48
  • @blip: It depends on the size of the budget deficit (or surplus) you run and how you much you allocate to fund the state insurance program relative to the other priorities in the states budget. Every state could afford it if that was the only thing they did with their tax revenue. But in fact, they have other budget items to fund too. Commented Mar 2, 2017 at 4:52
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    If you're arguing that without changing tax revenue it's not affordable, that's true, but that's true about any program. The idea behind a state system would be to increase taxes to pay for it (in exchange for lowering corporate and individual responsibility for buying it directly). So it's not exactly an affordability issue as much as a implementation issue.
    – user1530
    Commented Mar 2, 2017 at 5:42

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