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Chunhuei Chi is working on a plan that in much of the developed world sounds essentially banal, but to many Americans sounds so audacious as to be absurd.
If all goes as he predicts, in just a few years, Oregon voters would have the last word on universal health care.
When Chi, a veteran scholar of health care system finance, thinks about that politically freighted concept, a key point of reference is Taiwan. More than 30 years ago, on March 1, 1995, Taiwanese leaders hit the switch, activating a centralized administrative machine to provide universal health care benefits to the island’s 20 million-plus inhabitants.
Chi played a part in designing that machine. He had joined the project at the invitation of his doctoral adviser at Harvard, William Hsiao, who headed Phase 1 of the Taiwan project, which in time became the subject of global renown. In the decades since, over periodic summers and sabbaticals, Chi has returned to Taiwan to examine its National Health Insurance Administration further.
He has also long watched Oregon’s debate on the matter, such as in 2002, when voters overwhelmingly rejected a ballot measure to establish a single-payer health care system. Today, he stands among the small group racing toward a Sept. 15 deadline to submit to the Oregon Legislature a similar, highly ambitious proposal years in the making. The Universal Health Plan Governance Board, as it is known, has lately launched something of a road show, traveling from forum to forum around the state in order to prime Oregonians for the idea:
A centralized, publicly funded system providing health care coverage, with no deductibles or premiums, to every Oregonian.
Further details must be ironed out. Founded by state lawmakers in 2023, the board was tasked among other things with producing a detailed revenue plan that builds on the vision established by a prior task force. But, as The Lund Report recently documented, divisions on the board remain, and some, including those who support its premise, harbor serious doubts that it has made enough progress to deliver final recommendations by September. Meanwhile, to not a few people, this committee and its backers are engaged in what is essentially a bunch of talk—talk of a distant dream that in reality remains a financial and practical impossibility.
“I don’t see any way in the world this is going to happen,” state Rep. Ed Diehl (R-Scio), the vice chair of the House Interim Health Care Committee, told WW recently. He added, “You’re going to drive taxpayers of means out, and you’re going to drive very sick people in.”
Nonetheless, Chi and his cadre carry on. Over two interviews, consolidated here and edited for brevity and clarity, he discussed and defended a plan in which Oregon would take the vanguard in one of the great political fights of modern American life.
WW: Are we talking about a single-payer model here?
Chunhuei Chi: Yes, single-payer, tax-financed universal health care.
Is the vision that basically all Oregonians would be on something like the Oregon Health Plan?
Yes.
How would we pay for this, given that the Oregon Health Plan is pretty much broke right now?
Using taxation to replace what employers and Oregonians currently are paying for premiums. Substitute a premium with tax.
Right now—we don’t have the final version yet because we are still trying to get an accurate estimate of the cost—it’s mainly two sources of tax, plus a few others.
One is called the household health income tax. This is an earmarked income tax specifically for the universal health plan. The other is an employer payroll tax: a tax on the employer.
Again, this is not final. We are trying to determine who can be exempt. And this is in place of what currently employers are paying for their employees’ health insurance.
I know you’re still working out details, but would this cost employers more or less than the status quo in terms of what they pay for health premiums?
On average, less.
What about people in general? Would households pay less or more than the status quo?
We’re hoping people who currently qualify for Medicaid don’t have to pay anything. And that would be roughly about 200% of the federal poverty line.
Also, this will be progressive. People around the middle to 60th percentile income, they will pay less than in the status quo. And people who are on the higher end of income will pay more than the status quo.
You’re talking about funding health care for the entire state of Oregon. How could that possibly cost the same or less for so many people?
The design of the financing is to make it equitable in terms of a household’s ability to pay. I would say for at least half—but most likely more than half—of Oregonians, they will see their financial burden on health insurance less than the status quo.
Keep in mind, in this plan, there will be no cost sharing. And so when we say “pay less,” that’s including no co-payment, co-insurance, cost sharing.
And for employers?
If an employer currently offers average or above-average generosity of coverage, they will see either equal or less burden.
For employers who currently offer less or are currently not offering coverage, they will see their burden increase.
Again, we have not finalized it, but many small employers may be exempt from the employer payroll tax.
Why is the single-payer model the way to go?
That was the Joint Task Force on Universal Health Care consensus and recommendation. And Senate Bill 1089 [the 2023 law establishing the Universal Health Plan Governance Board] also assumed that.
Given that we don’t have the historical development like Germany’s sickness fund, it is more easy and efficient to have a single-payer universal system like Canada. Taiwan, South Korea, France and multiple European countries have that. Australia too.
Obviously, those are countries, and here we’re talking about a state. Is there anywhere in the world where, within a country that doesn’t have universal health care, a state or province does?
Temporarily, Canada. Canada’s universal health care started with the province of Saskatchewan. Saskatchewan started as the first province to implement universal care. But then the whole country replicated the system. The province of Saskatchewan tested the water. And then the nation agreed.
Yes, you have a good point. We are a state, not a whole nation. And so we face a lot of complications. And we are dealing with those complications.
For example, Medicare. Medicare is a federal program. So, part of our finance and revenue committee work is how to deal with Medicare beneficiaries.
A partial barrier is the 1974 ERISA law that exempted self-insured corporations who operate across multiple states from state regulation. We want to make this universal health plan coverage and finance as attractive as possible, so those corporations who are exempt—they will find it attractive and better off to join.
We have multiple committees. We have a plan design committee working on the benefit coverage. And we work even on details about very complicated situations, for people who work remotely in another state. That’s just one example.
Also we work on the details of who will be eligible. Again, this is not final, but what we propose is a person has to be living in Oregon for six months or longer to be eligible. That’s to avoid so-called medical tourism. Because one major concern is if Oregon implemented universal health care, then people from neighboring states may just travel here to get free treatment.
What other states are doing something like this?
Vermont probably was the first one. But they suspended it because of the cost. And then California. California started much earlier than Oregon. Unfortunately, they also suspended. The main reason for suspension was California was very ambitious to include universal health care with long-term care. And if you include long-term care, the cost will be quite substantial; that means the tax will be pretty high. Then you face resistance.
Washington state has a similar committee. The two states are about the same pace in terms of progress. There are other states in the process of planning.
You’ve been working in this space for decades. When you think about just your own quest to organize single-payer models, in Oregon in particular, is this the closest you think it’s ever been?
This is the closest. This is probably as close as ever.
Who doesn’t want this and why?
Of course, the private insurer—they are the strong opponent of universal health care.
One of the big, big barriers is social division. Because to have a sustainable universal care, society has to have a sense of community and solidarity. And in the multiple town hall meetings, I have been responding to the same question. People who oppose universal care make this question: Why should I pay for other people’s health care?
And people have those questions, often, out of ignorance. Because even with private health insurance, we are paying for other people’s health care.
In modern society, in any society, always the least healthy people consume the most health care. And you have to have the sense of community and mutual help. But also, you have to understand: Health conditions, a substantial part of that, is not something we can control.
There are many factors we don’t have control over. You can support universal health care out of self-interest—meaning out of self-interest and mutual help. Today I’m healthy, I’m able, I’m willing to help with your health care cost, with the expectation that tomorrow, if I become ill, I expect you to help me in return.
It’s a profound political challenge.
Yes. That part is not easy to communicate with the public.
The board is going to deliver its report later this year. What’s next?
The Legislature will play the key role in making the final decision. Initially they will review and very likely modify whatever we propose.
The Legislature will have two options. One is that they approve it and they send it to the governor’s office for the governor to sign off. The other option, which I’m predicting is more likely to happen, is, in the process of the Legislature’s review and debate, they don’t want to be the entity to make the final decision. So they will submit it for a ballot measure.
The 2028 ballot?
We are predicting that’s the timing. But it all depends on how long the Legislature needs to take to finalize it, to revise it.
