California Often Leads Change, but Not for Single-Payer Health Care

In 2022, a proposal to create the first single-payer health care system in California’s history so fractured the Democratic supermajority in the State Assembly that it never even came to a vote.

The powerful health industry lobby, along with Republicans and the state Chamber of Commerce, lined up to oppose it. The governor checked out of the conversation. Groups who had supported and pushed for the idea were left bitterly disappointed — and in some cases, feeling betrayed.
 

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Two years later, guaranteed health care for all is back on the docket, and things feel much the same. The opposition remains organized, the Democratic speaker of the California State Assembly already has cast significant doubt over the legislation’s chances, and Gov. Gavin Newsom has evinced no interest in the plan.

So, what’s actually going on here?

“We never give up,” said Cathy Kennedy, a registered nurse with Kaiser Permanente and co-president of the California Nurses Association. “We may have a moment when we stop and regroup, but at the end of the day we believe that health care is a human right — not a commodity.”

The wealthiest nations of the world would agree. The U.S. is the only high-income country that does not have universal health coverage, according to the Commonwealth Fund, and its health system ranks last among 11 high-income nations in terms of providing equitable and accessible care.

Viewed from that angle, this most recent effort in California is but another step toward realizing what other countries already know. And it seems there is always a next step.

The nurses’ union was one of several groups that rallied Tuesday in Sacramento in support of AB 2200, the latest single-payer legislation advanced by Assemblymember Ash Kalra (D-San Jose). Later that day, the bill passed the Assembly Health Committee, meaning it will move on to the powerful Appropriations Committee, where its fate will likely be determined. (Disclosure: The California Nurses Association is a financial supporter of Capital & Main.)

In a statement, Kalra called the preliminary vote “a significant accomplishment and a testament to the movement for single-payer health care. … California has the opportunity to be a model for the nation on what a progressive alternative to our fragmented, profit-driven status quo can be.”

But the reality is that Kennedy’s sentiment about not giving up is probably the most significant one here. Single payer, even in progressive California, has repeatedly proved a difficult sell in the halls of power at the Capitol, where lobbyist money runs deep and the health-industry behemoths spend freely.

The idea of a single-payer system in California certainly isn’t new, and it has been advanced in one form or another in state politics for decades without ever being implemented. The goal is a centralized health care program, most likely run by a government-created agency, that oversees care for everyone in the state, with no insurance premiums, co-pays or deductibles.

With the cost of such a program estimated at between $314 billion and $391 billion annually, supporters have to both identify the funding mechanisms and convince Californians they’d save in the long run because of the lower expenses associated with single payer.

It’s almost the opposite of the current, top-heavy insurance system in which most patients receive health care. Single payer is a direct threat to that very profitable system, and it is vehemently opposed by health industry lobbies like the California Hospital Association, California Medical Association and many others, who dismiss Kalra’s current legislation as a “costly, disruptive proposal that ignores California’s historic progress on health care.”

Kalra is no neophyte to all of this. He advanced CalCare, as the plan is called, in 2021 and 2022 before concluding he had nowhere near enough Democratic votes for that bill, AB 1400, to pass the full Assembly. Kalra chose to withdraw the legislation rather than force a vote that would have exposed fissures within his party. It was a move that left him open to second-guessing and anger from some of the groups who supported the bill.

But Kalra won’t give up on single payer in California because, for him, it is a deeply held personal issue first, and a political problem only second. Moreover, he clearly understands the Sisyphean task at hand. This isn’t a one-shot deal; it will require repeated efforts.

“The whole idea of transforming our health care system is not something that happens overnight. But it’s not going to happen at all if we don’t take first steps,” Kalra told Capital & Main during the latest round of legislative efforts. “This is about as big a step as we can take, at least in terms of what we aspire to.”

Newsom once aspired to the same, campaigning in 2018 on the notion of guaranteed health care for all and saying at one point, “Single payer is the way to go.” But once in office, the governor, whose heavy political contributors included Blue Shield and the California Medical Association, quietly backed away from the issue. Newsom chose instead to try for a mix of public and private insurance — including an expansion of Medi-Cal — so that almost all the state’s residents had some form of coverage, even if, as critics have consistently pointed out, the insurance is often too expensive for Californians to actually use.

Kalra has always understood the political and lobbying forces at work, as have the nurses’ union and other organized groups who continue to rally for a single-payer form of health care. But if there’s no bill, there is no conversation, and “every opportunity to have this conversation is an important one,” Kalra said.

So, it continues here in 2024. The United States spends more on health care than any other high-income country, with some of the poorest results. California itself cannot change a nation. But it can try to fix itself.

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