Why has California consistently failed to pass single-payer health care bills? The state has a Democratic super-majority in its legislature, strong unions and social movements, and the world’s fifth-largest economy. But despite these favorable conditions, California health care advocates have been unable to unite around a strategy. The organizing problems that have resulted have implications that go well beyond the fight for health care justice. Whatever their particularities, other social movements face the same kind of choices, and the experience of California’s single-payer movement has much to teach them.
A $4.5 trillion train wreck
The world’s most market-driven health care system is a $4.5 trillion train wreck. The United States spends twice as much as other countries for medical care, but by almost any measure—life expectancy, infant mortality, maternal mortality, health equity—its outcomes rank far behind.
The racial bias of US health care was painfully apparent during the COVID-19 pandemic, when Black and brown people died at two to three times the rate of whites. In other respects, the system’s abuses are remarkably indiscriminate. More than 100 million people in this country are burdened with medical debt, thanks to exploding costs and the proliferation of high-deductible health plans; one in four owe more than $5,000. Medical debt remains the leading cause of personal bankruptcy.
Like the housing market, the health care industry has become a magnet for big money, as huge aggregations of wealth seek new investment outlets. Private equity firms have bought up over 8,000 hospitals and private practices, at a cost of $200 billion a year; hospital takeovers have been accompanied by a drastic increase in infections, bedsores, and falls by patients, as bottom-line considerations increasingly drive staffing decisions. The new owner of one Pennsylvania hospital closed its maternity ward and emergency room to finance the takeover and rewarded stockholders with a $457 million dividend. To make matters worse, insurance companies are moving in on the Veterans Health Administration and Medicare, viable public programs now being privatized with startling speed.
The economics may be hard to grasp, but the consequences aren’t. Poll after poll has shown that the public would welcome a single, publicly financed system that does away with middlemen and profiteers and allows universal access to care. Ever since Bernie Sanders raised the issue in his 2016 presidential campaign, the progressive wing of the Democratic Party, and the left in general, have made single payer a litmus test for evaluating candidates for public office.
Why, then, does the goal remain so elusive? Objective conditions are part of it. The health care industry has plenty of money and is not shy about using it in the political arena. Organized labor has the resources and organizational infrastructure to counter it, but while unions would clearly benefit if their members’ health coverage were no longer held hostage at the bargaining table, conflicting political pressures make many of them hesitate to act. On an individual level, people may not feel a sense of urgency about the issue until they, or someone close to them, face an expensive medical emergency. At some point in our lives nearly all of us will find ourselves in this situation; at any given time, only a small minority of us do.
Finally, any attempt to implement single payer at the state level must get around a host of federal statutes and regulations, and needs to capture funds from various federal health care programs to help pay for it all.
None of these obstacles are insurmountable. But overcoming them requires more than moral outrage or a strong personal stake in the outcome. It requires a strategy—a clear sense of the forces involved, of potential allies and how they might be won over, of when to compromise and when to draw a line in the sand, of how to make connections with the larger struggle for social justice. Without such a strategy, and a broad and deep movement executing it, we will keep falling short. California offers an example of the problems that can arise when subjectivism replaces strategic thinking.
State solutions for a national problem
The health care crisis is a national problem that ultimately requires a national solution, but many single payer activists have concluded that the states are a more promising arena of struggle than a gridlocked Congress. California is as good a place as any to stand and fight. Insurance, whether public or private, is all about sharing risks, and the nation’s most populous state has enough people to constitute a massive risk pool. Nor does it want for financial resources: California is the world’s fifth-largest economy. It has a Democratic supermajority in the legislature and a politically ambitious governor who first rode into office in 2018 as a self-proclaimed single payer candidate.
California also boasts a robust immigrant rights movement that fought successfully to make undocumented people eligible for MediCal, California’s version of the federal Medicaid program for the poor. In a state where people of color are now a majority, there is enormous potential for a single payer movement that seriously engages with the fight for health equity.
For the third time in seven years, a single payer bill, AB 2200, has been introduced in the state legislature. The driving force behind all three bills has been the California Nurses Association, described by one observer as “on paper, the most progressive union in the state.” CNA is a serious force in California politics. In 2016, its support vaulted Bernie Sanders into effective contention in the Democratic presidential primary. More than once, it has led the opposition to the well-funded right-wing initiatives that crop up with depressing regularity on the state ballot. It derives genuine moral authority from its members, on the front lines of the state’s health care crisis, who put their lives in on the line during the COVID-19 pandemic.
In 2017 a CNA-led coalition shepherded the first of the three bills, SB 562, through the state Senate, only to have the Speaker of the state Assembly prevent a floor vote there—apparently to protect then-governor Jerry Brown from a politically embarrassing veto. CNA then dissolved its coalition and began working on a new bill, CalCare (AB 1400). Other organizations that had worked for SB 562 (among them Physicians for a National Health Program and the National Union of Healthcare Workers) formed a new coalition, Healthy California Now, but HCN was not invited to help draft the new bill.
Though it would retain much of the language of SB 562, CalCare had significant differences. They carried a stiff political price. At issue was the future of Kaiser Permanente, a health maintenance organization (HMO) that enrolls one in four Californians and has collective bargaining agreements with tens of thousands of union members. The language in the new bill raised questions about whether Kaiser would continue to exist if it passed and, if so, how it would function.
What do we do about Kaiser?
HMOs like Kaiser differ from other insurance plans because they combine financing with actual delivery of care. Since they eliminate the adversarial relationship between insurers and health care providers, they are promoted as a way to cut costs. In reality, any economies they achieve are effectively undercut by the dictates of the capitalist market. Kaiser’s hospitals and affiliated physicians offer a high level of care coordination that is relatively easy for patients to navigate; for that reason, many Californians prefer its model of “integrated delivery.” But the Kaiser Foundation Health Plan holds the purse strings, and while it’s technically a non-profit, market share and bottom lines drive its decisions.
The consequences are predictable: patients whose conditions are less profitable to treat often get shoddy treatment. Kaiser’s track record on behavioral health is a public scandal; its mental health workers have repeatedly hit the picket line trying to get better care for their patients. It is under investigation for fraudulent Medicare claims, and an incident where a Kaiser patient was illegally ”dumped” on the street figured prominently in Michael Moore’s popular documentary, “Sicko.”
Notwithstanding Kaiser’s well-publicized commitment to preventative care, its health plans have deductibles running as high as $14,000, virtually assuring that enrollees in its “affordable” premium plans will put off seeing a doctor as long as they can. It recently imposed rate hikes of up to 20 percent for unionized public employees. Taxpayers are footing the bill, and Kaiser apparently expects unions to take the rap for it.
There is a general agreement among single payer supporters that Kaiser needs to get out of the insurance business. The question is how. SB 562 tried to correct its abuses with detailed language regulating its behavior. It sought to minimize discrimination against “unprofitable” patients by requiring uniform standards of care for all providers and allowing anyone, not just Kaiser members, to access its system.
CalCare takes a different approach: it assumes that HMOs can’t be tamed. Because their financing depends on the number of patients they enroll rather than the actual cost of treating them, the reasoning goes, they have a built-in incentive to avoid sicker patients and concentrate on healthier ones, and no statutory language can prevent it. Both AB 1400 and its current version, AB 2200, removed all the language in SB 562 relating to care coordination and integrated delivery.
There is a spirited debate among health policy experts over whether HMOs have any place in a “true” single payer system. To Californians whose main concern is to get the care they need when they need it, it may be an academic question. But it still troubled some unions that had supported SB 562. Not having been consulted about the content of AB 1400, they viewed it with suspicion and were slow to endorse it.
Unions representing Kaiser employees were even less enthusiastic. Most single payer bills recognize the need to provide for workers displaced when private insurance is eliminated; they specify that when the new publicly funded plan recruits its work force, these workers get first crack at the jobs. But Kaiser is not just an insurance plan. Thousands of people work in its hospitals and outpatient facilities as well. What would a massive reorganization of Kaiser’s delivery system mean for their jobs and union contracts?
Concerns like these undermined support for AB 1400 and gave wavering legislators an excuse to bail. AB 1400 could not even get a floor vote in one house of the legislature, let alone two. Undaunted, CNA spent 2023 drafting a new version of CalCare, introduced in early February of this year as AB 2200. While it contains significant improvements, its approach to HMOs is essentially unchanged, though it does allow Kaiser enrollees to remain with the HMO during the transition to a public plan.
Small steps to single payer
In the meantime, Healthy California Now succeeded in passing SB 770. Not an actual policy bill, it seeks to remove both the legal and political barriers to passing one—first, by getting around the various federal regulations that might interfere with implementation of a state plan; second, by creating a “stakeholders process” which HCN hopes to use to broaden the base of support for single payer. Clearly, it matters who engages in the process, and HCN has launched a series of meetings with labor, community, and health advocacy groups to draw them in.
On the face of it, there would not appear to be a conflict between SB 770 and CalCare. But SB 770 carried an implicit assumption that CNA, working on its own, was not capable of mobilizing a broad enough base of support to actually pass single payer legislation. Not surprisingly, CNA took strong exception. It actively mobilized to defeat SB 770—to the dismay of legislative allies who supported both bills. It charged that SB 770 was unnecessary at best, and at worst amounted to sabotage. The stakeholder process, it was charged, could be used either to water down CalCare or block its passage altogether.
Some CalCare partisans went further. A rump group in Health Care for All-California tried to get it to withdraw from Healthy California Now and, when the effort failed, formed its own breakaway organization. The Los Angeles chapter of Democratic Socialists of America saw a similar breach. A dissident local of Physicians for a National Health Program, opposed to SB 770, is now claiming to represent the “real” state organization. Both PNHP and HCA-CA, it should be noted, have a long history of fighting for single payer in the state, and both worked actively to pass AB 1400.
On the surface, this has all the earmarks of a turf war. CNA feels it has earned its leadership role in the state single payer movement and is wary about sharing it. For their part, its critics feel the split is more about process than policy, making the situation all the more frustrating. Indeed, the policy differences involved are technical enough that it’s hard to see why they should generate such passion. Merely understanding them requires a level of expertise that many people don’t have.
The art of compromise
We’ve all seen this movie before. Sectarian behavior has long bedeviled the Left, and organized labor has been weakened time and again by bitter jurisdictional disputes. Whenever this happens, the term “narcissism of small differences” is often invoked to explain it.
But it does not explain nearly enough. Successful social movements are those that find a way to “unite all who can be united.” It seems like common sense, but it also requires far more than just a clear goal and a commitment to making it happen. Organizers must weigh the practical consequences of every choice: will this expand the movement’s impact and reach, or limit them?
The policy differences at issue in California may be technical, but they are still real. The big question is what is gained and what is lost by raising them to the level of principle. In determining whether a particular compromise is acceptable, it helps to remember that state single payer legislation is itself a compromise. National legislation would clearly be preferable. For that matter, if the goal is to get profits out of health care, delivery as well as financing should be a public responsibility. Even a fully public health care system needs to be constantly defended against capitalist attack—witness the fate of Britain’s revered National Health Service, reduced to a shadow of its former self by years of neo-liberal budget cuts.
And not all compromises are driven by the same logic. Any good union negotiator will tell you that in an adversarial situation, you come to the bargaining table with your maximum set of demands and give ground only when your adversary is willing to reciprocate. But building an effective working relationship among potential allies involves a different kind of compromise, one that recognizes that people who want the same thing may not be coming from the same place. In such situations, compromises are not a matter of “giving ground” but of avoiding needlessly divisive issues so that we can unite against the common enemy.
The notion that a particular reform can be foolproof if it is properly crafted and shuns compromise reflects a certain class perspective. Historically, health care providers—both nurses and physicians—have been the driving force in the single payer movement. Up to a point, this makes perfect sense. They experience the system’s failings on a daily basis, and their experience provides a special insight into the root causes. What it does not offer, in and of itself, is the social power to change the system.
Patient power for the win
The medical profession requires a high level of training and skill, and doctors have traditionally enjoyed autonomy and independence at work—something that is being lost as the practice of medicine is increasingly corporatized. Doctors complain that the system undermines their clinical judgment, that every treatment they prescribe has to be justified to an insurance claims adjuster or “managed care” functionary who may know nothing about medicine but still wants evidence that the treatment will justify its expense.
Nurses are also skilled workers, traditionally undervalued but now represented by strong unions in many parts of the country. An acute nursing shortage has forced them to battle understaffing and unsafe working conditions, but it has also increased their clout at the bargaining table. And CNA wields enough political clout that California politicians think twice before crossing it. It is hard to imagine an effective single payer movement without its resources and organizing chops.
But even CNA can’t do it alone. In a hospital, doctors prescribe a course of treatment and nurses carry it out. The patient’s role is essentially a passive one. In the fight for single payer, however, it is ultimately the organized power of the patients that will make the difference, and for most patients, a dysfunctional health care system is only one of a number of social injustices they must grapple with daily. Single-issue politics will not work for them. Even their health problems can frequently be traced to conditions that go well beyond lack of access to medical treatment—poverty, a shortage of affordable housing, poor nutrition, immigration status, environmental racism.
Significantly, California’s most notable victory in the fight for health care justice was not accomplished by single-payer forces. It was the work of an alliance of health care activists and the immigrant rights movement that fought successfully for inclusion of the undocumented residents in California’s version of Medicaid. This was achieved despite language in the Affordable Care Act (Obamacare) that explicitly bars the undocumented from getting federal health care funds. The victory was won not in one fell swoop, but step by step, beginning with extending eligibility to children and then demanding more.
An effective movement is one that makes connections—among constituency groups and among issues. Strong alliances are built not just by approaching the uncommitted and persuading them that your agenda matters to them, but by embracing their agenda as your own, developing relationships based on trust and mutual support. Unity is built through common struggle around immediate demands that deepens the relationships among those involved and broadens everyone’s grasp of the larger stakes. It means respecting the interests of your allies, knowing where they are coming from and recognizing that your differences matter less than what you have in common.
In short, it means thinking strategically, a skill that single-payer advocates—and Left activists generally—need to master.
Featured image: Rally at the California State Capitol in support of MediCal expansion, May 2014. Photo from the California Immigrant Policy Center.