On What Just Happened to Medicare for All in California--and the Organizing We Need to Win

Why is a healthcare system--Medicare for All--that costs less described as "too expensive?"

Why hasn't the overwhelming popularity of Medicare for All--85% of Democrats, 66% of independents and 52% (!) of GOP support it--translated into legislative majorities?

We need a healthcare justice coalition guided by a strategic assessment of what it will take to win with the ability to communicate effectively against the industry's lies.

Why is Medicare for All, a version of which is utilized in 50 countries around the world, presented as 'untested?'

The recent demise of the Medicare for All style reform bill in California, AB 1400, reveals some answers. The Wall Street Journal, who haven't met a for-profit healthcare model they don't like, suggest that if Medicare for All cannot be done in California, it won't happen in the United States. And the opposite is more likely true: if we can do it in California, Medicare for All will be adopted nationally.

AB 1400, also known as "CalCare" sponsored by the California Nurses Association/NNU, was the latest version of a single-payer bill to be considered in the California Legislature designed to help lead the US towards Medicare for All. Since the 1994 ballot initiative for single payer that was heavily defeated--it received fewer votes than the petition signatures gathered to put it on the ballot--numerous single payer bills have passed one or both houses of the legislature, and those that made it to the Governor's desk were vetoed.

Many advocates were encouraged when Gov. Gavin Newsom campaigned in support of the prior bill, SB 562, since the lack of gubernatorial support had proven fatal to reform efforts. As a result, the Healthy California Now coalition of organizations sought to hold Newsom to his promise and to utilize the Healthy California for All Commission he sponsored to move a single payer agenda. The pandemic delayed that Commission's work, but it is on track to release a report in April likely favorable to what they term "unified financing," having issued reports that demonstrated the unsustainability, inequities and expense of the present healthcare system compared to the cost and coverage advantages of single payer.

Rather than wait and rely on the Governor's leadership, advocates sought to rally around a bill as the preferred organizing strategy and a necessary policy step to apply for the approvals from the Biden administration necessary to finance a state single payer program (known as ACA Section 1332 waivers).

The resulting bill AB 1400 faced significant hurdles in the California Assembly, which has a large contingent of pro-corporate Democrats, despite a nearly three-fourths Democratic majority (which has been eroded by early retirements). To protect its profits and power, the healthcare industry--the insurance companies, corporate hospital chains, and prescription drug corporations, which can charge whatever they want, choose our doctors, and restrict access to treatments--rolled out a series of lies:

• Expensive and unproven approach to health care (only the US relies upon commercial insurance to allocate healthcare)
• Removes consumer choice (of health plans, such as it is)
• Threatens California's ability to respond to future public health emergencies (as if the present system has done such a great job addressing Covid-19)
• Californians need a stable health care system we can rely on (which is why we need single payer).

The Assembly Speaker required the AB 1400 author, Assembly member Ash Kalra, to develop a financing plan as a condition to move the bill through the legislative process. After eight months of work, Kalra complied in late December. With the introduction of the financing plan, known as ACA 11, the debate focused on the taxes necessary to replace the current premiums, co-payments, and deductibles: the media narrative adopted the industry perspective and highlighted the supposed costs of single payer.

No one mentioned that the "private taxes" workers and employers pay for healthcare are the greatest financial burden faced by the middle class, as the Commission had shown. Nor did we hear about the much greater expense of the present system ($517 billion in 2022!) even though it provides less benefits, is hugely inequitable, and includes out of pocket costs of $2000 per year from each Californian just for the administration of the commercial insurance system. AB 1400 proponents didn't utilize the very favorable studies and analysis provided by the Commission--the Los Angeles Times pointed to one study after the fact, but it's not just "supporters" who assert single payer will cost less (see researchers from UCSF review of 22 financing studies, 20 of which show savings from single-payer).

The bill moved to the Assembly Health Committee, where it passed 11-3 in early January. Time was of the essence, since for the bill to advance to the state Senate, it had to pass the Assembly by January 31st.

At this point significant changes in AB 1400 were made to how the bill's policies would be implemented. Rather than go through the legislature this year never to return, amendments were adopted that required the bill's governing board to apply for the necessary federal support, review and certify the sufficiency of the financing plan, and report back to the legislature which would have to vote again by July 1, 2024, to implement the resulting program, and send the financing plan to the voters for ultimate approval. In short, AB 1400 expressed the intent of the legislature and set up a process for implementation that depended on legislative votes and on winning a ballot initiative.

Given existing provisions in the California constitution regarding the size of the state budget and revenues devoted to education, a ballot initiative seemed inevitable to most observers, but many advocates presented a successful adoption of AB 1400 this year as "enacting CalCare," which was not the case.

The message environment matters, and single payer proponents are not winning the media narrative.

So how much of a setback is Assembly member's Kalra decision not to bring up AB 1400 for a vote? Rather than risk a double-digit defeat and solidify a negative position among colleagues whose support he needs and expects, Ash Kalra opted to fight another day. Advocates expressed outrage and a sense of betrayal. It's appropriate to hold elected officials accountable by forcing them to go on record on a bill, if we are prepared to act electorally to replace them, including having a fund and organizing strategy for credible primary challengers. That wasn't the case here. AB 1400 has been characterized as the only true single payer bill in California history, yet all of its provisions were subject to federal approval and further state legislative review.

In fact, the "first step" established by the amended AB 1400 can still be taken by the Governor with legislative authorization if necessary and incorporating the Commission's analysis and the key principles put forth in AB 1400. Once the federal support and approval for financing and program is secured by the Newsom administration, the California Legislature could approve it and send it to the ballot. The timeline would be at least as soon as in the amended AB 1400. There can be a convergence of state legislative and executive approaches.

Much has been accomplished. AB 1400 supporters organized the most comprehensive grassroots digital lobbying campaign ever, building a key infrastructure for future campaigns. The bill received significant endorsements, though the organizations including unions, that provide campaign funding and volunteers to elect Democrats did not make AB 1400 a priority. Organizational capacity to take on the industry was insufficient. There is also not a sufficient working-class base, particularly in non-union workplaces and during labor disputes, demanding single payer as the solution to the on-going healthcare crisis, and especially to the inequities exposed by the pandemic. We need to bring the diverse healthcare reformers who are in Sacramento everyday urging immediate improvements to pressure legislators for single payer. We need to be able to persuade and if necessary, force politicians to guarantee healthcare--not simply adopt "universal coverage" with all its gaps and disparities--whether they or their donors want to or not. That takes greater organizational and institutional support, and base building, in addition to activist mobilization.

The message environment matters, and single payer proponents are not winning the media narrative. Our slogan could be "We Care, They Scare. Better Healthcare, Not Bigger Profits." We must educate and inoculate voters, which takes door-knocking, earned media and paid ads, funded by tens of millions of dollars over a few years. Once the industry funded TV campaign begins against a ballot initiative--and we can expect based on recent ballot fights $200 million to publicize their lies about high costs, taxes, unreliability, lost jobs and limited choice under single payer--we'll need to be on TV, too.

This year in California we can establish the building blocks for single payer--seeking federal support, covering undocumented residents, setting up the infrastructure to set a state healthcare budget and rates, establishing a "single payer" for prescription drugs, and unwinding the for-profit domination of the state's low-income health program, Medi-Cal.

We need a healthcare justice coalition guided by a strategic assessment of what it will take to win with the ability to communicate effectively against the industry's lies. Can one bill do it all? Maybe not. But strategic organizing can.