SACRAMENTO 鈥� Single-payer health care didn鈥檛 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 鈥� 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 鈥渦niversal health care,鈥� which aims to provide all Californians with coverage but, unlike single-payer, would keep private health insurance intact.
Newsom鈥檚 retreat devastated progressive activists and the powerful California Nurses Association union, which championed the cause. The death of single-payer in the nation鈥檚 most populous state also deals a major blow to similar campaigns elsewhere in the nation 鈥� which had looked to California for inspiration and leadership 鈥� casting doubt on their ability to succeed.
鈥淲e鈥檙e also fighting in New York, but just like in California, there鈥檚 not 100% Democratic consensus among legislators,鈥� said Ursula Rozum, co-director of the Campaign for New York Health, which is working to pass single-payer legislation. 鈥淚t feels like a constant question of 鈥楥an we win this?鈥欌��
Health policy experts agree that California鈥檚 failure to adopt single-payer dampens momentum across the country.
鈥淐alifornia, 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,鈥� 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 California鈥檚 failure: It is essential to win 鈥� and keep 鈥� 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.
鈥淲e鈥檝e 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,鈥� Rozum said. 鈥淎nd just like there, our union movement is divided. We know we need them to have any chance of moving forward with our bill.鈥�
So far, single-payer proponents haven鈥檛 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, didn鈥檛 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.
鈥淭here isn鈥檛 a political party in the world that鈥檚 going to raise their hands every year to increase taxes on hard-working citizens,鈥� Shumlin told KHN. 鈥淭hat鈥檚 the big mistake I made in Vermont.鈥�
But progressive dreams for single-payer didn鈥檛 die when Vermont retreated. 鈥淢edicare for All鈥� 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 鈥� or they鈥檒l be confronted with the political difficulty of constantly raising taxes.
鈥淐alifornia is the best state to lead this because it has the fifth-biggest economy in the world. It鈥檚 all about scale,鈥� Shumlin said. 鈥淎nd if California gets it right, other states and the federal government will follow. But this is hard stuff, so get ready to get bloodied.鈥�
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 Newsom鈥檚 first day in office in 2019, he said, 鈥淚 committed to this and I want folks to know I was serious.鈥� But since then, he has distanced himself from single-payer.
I鈥檓 tired of politicians saying they support single payer but that it鈥檚 too soon, too expensive or someone else鈥檚 problem.
鈥� 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 can鈥檛 simply approve the request 鈥� California would need complicated federal waivers and approval from Congress.
Newsom has shifted to a platform of 鈥渦niversal health care,鈥� which includes Medicaid coverage for all income-eligible unauthorized immigrants and state-funded subsidies for Californians who buy health insurance from Covered California, the state鈥檚 Obamacare insurance exchange.
Newsom said in January that he has long believed single-payer is 鈥渋nevitable鈥� 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 couldn鈥檛 muster enough support.
鈥淚t makes it harder to get the votes you need when I鈥檓 trying to convince my colleagues that there鈥檚 an absolute path to success,鈥� Kalra said. 鈥淲e have a governor who campaigned on single-payer, and if we鈥檙e going to successfully have single-payer health care in California, at some point we need his engagement and it needs to be genuine.鈥�
Kalra said he鈥檚 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.
鈥淭here鈥檚 no question that had California passed a single-payer health care plan, we鈥檇 be in a position in the state of Washington to say, 鈥楲ook what California is doing,鈥欌�� 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 California鈥檚 single-payer campaign this year, helping with a phone-banking campaign to pressure lawmakers. He鈥檚 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. 鈥淲e鈥檝e learned all the ways Democrats can kill a bill, but we can鈥檛 spend all of our time grieving this loss and the huge setback that it is,鈥� 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.
鈥淎s trade unionists, we believe everybody should have health care, but there鈥檚 a big fear that we鈥檙e going to lose the benefits that we have,鈥� said Chris Snyder, political director for the local International Union of Operating Engineers in Northern California. 鈥淲e have our own health care trust fund, and we don鈥檛 want benefits that we鈥檝e fought for for decades to be taken away or watered down.鈥�
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.
鈥淲hat is keeping the bill from moving in the legislature is opposition from public employee unions,鈥� Gottfried said. 鈥淭hey 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.鈥�
Gottfried said he has been negotiating with teachers, sanitation workers, and other trade unions on legislative language that would provide 鈥渕ore explicit guarantees鈥� that union members would receive better coverage without paying more out-of-pocket than they already do.
It鈥檚 not clear if the measure will get a vote this year.
鈥淲hichever state goes first will help build momentum for other states,鈥� he said.
This story was produced by , which publishes , an editorially independent service of the .