SACRAMENTO Single-payer health care didnt stand a chance in California this year.
Even in this deep-blue bastion, Democratic lawmakers shied away from legislation that would have put state government in charge of health care and taxed Californians heavily to do so a massive transformation that would have forced them to take on the powerful health care industry.
Gov. Gavin Newsom, who had promised to spearhead single-payer when he ran for governor four years ago, dashed its chances this year when he declined to publicly support it.
Instead, the first-term Democrat, who is running for reelection this November, is pushing for universal health care, which aims to provide all Californians with coverage but, unlike single-payer, would keep private health insurance intact.
Newsoms retreat devastated progressive activists and the powerful California Nurses Association union, which championed the cause. The death of single-payer in the nations most populous state also deals a major blow to similar campaigns elsewhere in the nation which had looked to California for inspiration and leadership casting doubt on their ability to succeed.
Were also fighting in New York, but just like in California, theres not 100% Democratic consensus among legislators, said Ursula Rozum, co-director of the Campaign for New York Health, which is working to pass single-payer legislation. It feels like a constant question of Can we win this?
Health policy experts agree that Californias failure to adopt single-payer dampens momentum across the country.
California, given its size and politics, has always been a bellwether for progressive policy, so this certainly sends a signal to other states about how hard this is, said Larry Levitt, executive vice president for health policy at KFF.
But Rozum and single-payer activists in Colorado, Washington state, and elsewhere say that rather than giving up, they are taking key lessons from Californias failure: It is essential to win and keep support from the governor. Groups pushing single-payer must unite Democrats, bringing in business-friendly moderates and broader support from organized labor. And they say they must learn how to counter intense lobbying by doctors, hospitals, and health insurance companies fighting to preserve the status quo.
Weve seen what happened in California, so we are working hard to get our governor on the record in support of single-payer so she will sign it when it gets to her desk, Rozum said. And just like there, our union movement is divided. We know we need them to have any chance of moving forward with our bill.
So far, single-payer proponents havent been able to broaden their movement beyond liberal activists or convince people that they should pay higher taxes in exchange for scrapping health care premiums, deductibles, and copays.
The only state that has passed single-payer, Vermont, didnt implement it.
Vermont adopted a single-payer plan in 2011 with unequivocal support from its then-governor, Democrat Peter Shumlin. But he abandoned the effort in 2014 amid growing concerns about tax increases and runaway health care costs.
There isnt a political party in the world thats going to raise their hands every year to increase taxes on hard-working citizens, Shumlin told KHN. Thats the big mistake I made in Vermont.
But progressive dreams for single-payer didnt die when Vermont retreated. Medicare for All became a liberal rallying cry for Democrats nationally when Vermont Sen. Bernie Sanders stumped for it during his presidential campaigns. After President Joe Biden was elected, the movement shifted to the states, in part because Biden has .
Activists in Colorado are mobilizing for another single-payer campaign after the of a 2016 ballot initiative that failed . Organizers in Washington state are pushing legislation and trying to get a single-payer initiative on the ballot next year.
Shumlin said Democrats must be prepared to take on deep-pocketed industry groups and rein in soaring health care spending or theyll be confronted with the political difficulty of constantly raising taxes.
California is the best state to lead this because it has the fifth-biggest economy in the world. Its all about scale, Shumlin said. And if California gets it right, other states and the federal government will follow. But this is hard stuff, so get ready to get bloodied.
Some Democratic lawmakers and the California Nurses Association had hoped California would lead the way this year and that Newsom would be their champion.
State Assembly member Ash Kalra (D-San Jose) introduced legislation sponsored by the union that would have created government-run health insurance for all state residents while significantly raising taxes on employers, employees, and businesses to pay for it. State estimates pegged the cost at roughly , with a little less than half coming from tax increases and the rest from the federal government.
On Newsoms first day in office in 2019, he said, I committed to this and I want folks to know I was serious. But since then, he has distanced himself from single-payer.
Im tired of politicians saying they support single payer but that its too soon, too expensive or someone elses problem.
— Gavin Newsom (@GavinNewsom)
Instead, he has created a commission to study the concept and asked for permission to collect federal money that flows to the state via the Affordable Care Act, Medicaid, and Medicare, which California could use to help finance a single-payer system. But Biden cant simply approve the request California would need complicated federal waivers and approval from Congress.
Newsom has shifted to a platform of universal health care, which includes Medicaid coverage for all income-eligible unauthorized immigrants and state-funded subsidies for Californians who buy health insurance from Covered California, the states Obamacare insurance exchange.
Newsom said in January that he has long believed single-payer is inevitable but signaled that the federal government should take the lead.
Kalra decided not to bring his bill up for a vote in the state Assembly, saying on Jan. 31 that he couldnt muster enough support.
It makes it harder to get the votes you need when Im trying to convince my colleagues that theres an absolute path to success, Kalra said. We have a governor who campaigned on single-payer, and if were going to successfully have single-payer health care in California, at some point we need his engagement and it needs to be genuine.
Kalra said hes considering introducing another bill next year but conceded that he must shift his strategy to bring more Democrats and unions into the campaign.
These are lessons other states are heeding.
Theres no question that had California passed a single-payer health care plan, wed be in a position in the state of Washington to say, Look what California is doing, said Andre Stackhouse, campaign director for , an advocacy group trying to get a single-payer initiative on the ballot next year.
Stackhouse worked on behalf of Californias single-payer campaign this year, helping with a phone-banking campaign to pressure lawmakers. Hes part of a new national coalition called Medicare for All Everywhere, a group of organizers and volunteers working to identify why single-payer efforts fail and how to overcome political and lobbying obstacles.
California was a key test, he said. Weve learned all the ways Democrats can kill a bill, but we cant spend all of our time grieving this loss and the huge setback that it is, Stackhouse said.
For instance, a major goal for the movement is to persuade more unions to join the fight. Although the nurses union is leading the battle in California, other unions are against single-payer.
As trade unionists, we believe everybody should have health care, but theres a big fear that were going to lose the benefits that we have, said Chris Snyder, political director for the local International Union of Operating Engineers in Northern California. We have our own health care trust fund, and we dont want benefits that weve fought for for decades to be taken away or watered down.
Lack of union support is a major problem in New York, where Democratic Assembly member Richard Gottfried has introduced a single-payer bill in every legislative session for the past 30 years.
What is keeping the bill from moving in the legislature is opposition from public employee unions, Gottfried said. They feel they have negotiated excellent coverage, so we need to convince them that the New York Health Act is as good or better than what they have now.
Gottfried said he has been negotiating with teachers, sanitation workers, and other trade unions on legislative language that would provide more explicit guarantees that union members would receive better coverage without paying more out-of-pocket than they already do.
Its not clear if the measure will get a vote this year.
Whichever state goes first will help build momentum for other states, he said.
This story was produced by , which publishes , an editorially independent service of the .
