Why single-payer advocates are split on how to overhaul health care

For many Californians, the proposal of a state-run single-payer health system remains a ‘pie-in-the-sky’ idea, and odds are it could remain that way, especially if leading advocates can’t agree on how to get there.

Democratic leaders and advocates who are looking to transform the current complex health care system are divided on their approach. On one side, a coalition of health, labor and civil rights advocacy groups is standing behind Senate Bill 770, which seeks an incremental path toward “unified financing,” where a statewide system would pay for health care for all residents. This could be single-payer or a similar model. The bill would task a workgroup of experts and consumers to come up with next steps in advancing toward this goal and deliver a report to the Legislature by next June.

SB 770 also calls for the Newsom administration to engage the federal government, which would need to approve such a system in California, on this issue. The bill, authored by San Francisco’s Sen. Scott Wiener, is currently making its way through the Legislature — last week, it received the green light from the Assembly Health Committee and is headed to a fiscal committee next.

On the other side, the California nurses union, a longtime driving force behind the single-payer movement, opposes Wiener’s bill, arguing it could derail its own legislation, Assembly Bill 1690. That two-year bill authored by Assemblyman Ash Kalra, a San Jose Democrat, would establish a single-payer system dubbed CalCare. The bill was introduced earlier this year but won’t come up for a hearing until the next legislative session. There are currently no details in the CalCare bill, but union leaders said they are using their previous attempt at single-payer, Assembly Bill 1400, as a starting point. AB 1400 died last year after its author, Kalra, opted not to take it up on the Assembly floor because he was short on votes.

Last week, Kalra joined the nurses union in publicly opposing Wiener’s bill, calling it a “detraction” from his and the nurses’ ongoing efforts.

Single-payer has been politically dicey even in blue California because of pushback from the health industry, including health insurers and some physician groups, but also powerful business interests, such as the Chamber of Commerce, citing the tax hikes that would be needed to fund such a system. Still, the status quo costs too much and leaves too many people behind, experts and health advocates say.

Carmen Comsti, lead regulatory policy specialist with the California Nurses Association, said the two bills are conflicting because legislators can use Wiener’s bill as an excuse to vote down the bill backed by the nurses union next year.

“We do not believe the Legislature would pick up and pass single payer if they just authorized another work group to consider the program,” Comsti told CalMatters. Instead, it opens the door for legislators to say: “It’s too soon to talk about CalCare and single payer because we’re studying it,” she said.

But Wiener and those supporting his proposal see the two bills as complementary, not conflicting. For example, to carry out a single-payer system, California would need to eventually seek a waiver, or permission from the federal government, to skirt current rules that dictate how the state can spend federal health dollars. Wiener’s bill would start those conversations, the author said.

“If CalCare passes, then at that point California will go to the federal government and make waiver applications. The work here, having those discussions with the federal government will be helpful; it dovetails,” Wiener said during last week’s hearing.

Some Democrats who sit on the Assembly Health Committee noted they see Wiener’s bill as a way to get the ball rolling on single-payer while they wait for wider support from their colleagues.

Kevin McCarty, a Sacramento Democrat, noted the nurses’ single-payer bill last year was “dramatically short” on votes. “It’s nowhere close,” McCarty said. “In the meantime, are we going to be purists or try to get more? That’s what I think (SB 770) is trying to do. I don’t think they’re mutually exclusive.”

Michael Lighty, president of the coalition sponsoring Wiener’s bill, said the point is to follow up on the findings from the Healthy California for All Commission, a group assembled by Gov. Gavin Newsom. The group’s work culminated last year in a 105-page report, but no action.

Lighty is a veteran in the single-payer movement and, at one point, worked as the director of public policy for the nurses union. The California Nurses Association is actually part of the health coalition he leads, but on this particular piece of legislation, they haven’t seen eye to eye.

Another main concern for the nurses union is the language used in the commission’s report and Wiener’s bill. “Unified financing does not equal single payer,” Comsti said. She argued that if “unified financing” includes programs that leave room for health insurers or any middlemen to profit, then that essentially goes against the single-payer system they’re seeking.

Lighty sees the language argument as an issue of nomenclature; ultimately, both sides want the same outcome, he said. And after multiple failed attempts to get to single-payer, perhaps it’s time for a new way in, he said.

“To get the Legislature to adopt a full blown single-payer program in one fell swoop has not proven to be viable politically,” Lighty told CalMatters.

By 2031 health care spending in California is projected to increase by $158 billion; a “unified finance” system can help slow down that growth, according to the Healthy California for All Commission report. Most importantly, extending coverage to all Californians could save about 4,000 lives a year, the report said.

“Folks on both sides of this bill have historically worked very closely together on expanding health care access,” Wiener said. “There is this disagreement now and I hope in the future that rift heals, but we all want the same result. We want everyone to have true universal access to health care.”