To those on the left side of the political balance beam, no issue is more important – or more elusive – than having medical care provided directly by a governmental system.
Dubbed "single-payer," it would eliminate insurers and other aspects of private enterprise from medical care and provide everyone the same services, regardless of income or other characteristics.
Not surprisingly, those who want it were elated when, in 2018, California's leading Democratic candidate for governor virtually promised to deliver it.
"I'm tired of politicians saying they support single-payer but that it's too soon, too expensive or someone else's problem," Gavin Newsom said.
Newsom's pledge won him support from single-payer advocates such as the California Nurses Association. It decorated a bus with Newsom's face and the words, "Nurses Trust Newsom. He shares our values and fights for our patients," and toured the state.
Once elected, however, Newsom sidled away from his pledge, saying his goal was universal health coverage, not necessarily single-payer.
"I think that the ideal system is a single-payer system," Newsom said in 2022 when pressed by reporters about his pledge. "I've been consistent with that for well over a decade. … The difference here is when you are in a position of responsibility, you've gotta apply, you've gotta manifest, the ideal. This is hard work. It's one thing to say, it's another to do. And with respect, there are many different pathways to achieve the goal."
Incrementally, he and the Legislature expanded Medi-Cal to groups lacking coverage, such as undocumented immigrants. Those actions, plus the mandates and subsidies of "Obamacare," eventually resulted in 94.8% of Californians being covered, according to a recent UCLA survey.
The issue arose again this year with two measures in the Legislature: one creating a framework for a universal system, and the other a tax increase on businesses to finance it.
The tax proposal would raise about $150 billion a year to offset the loss of employer-provided coverage, roughly a third of the estimated cost of a single-payer system for nearly 40 million Californians. The remainder would, in theory, come from pooling money already being spent by federal, state and local governments.
The tax measure went nowhere but the other bill, Senate Bill 770, was signed by Newsom last week.
SB 770 directs state officials to negotiate with federal authorities for a waiver under which money now flowing into health care from Washington – roughly 50 percent of the state's total public and private medical expenditures – would be given to the state.
It would finance a "comprehensive package of medical, behavioral health, pharmaceutical, dental, and vision benefits, which includes primary, preventive and wellness care services," according to the legislation.
It doesn't specify a single-payer system, and some advocates, particularly the nurses' association, opposed it. It described Newton's approval of SB 770 as "a complete betrayal of nurses' fight for a single-payer health care policy, a fight striving to achieve health justice for our patients and our communities."
However, other advocates see SB 770 as advancing the concept because federal financing is critical.
At most, SB 770 is a baby step. Getting the feds to chip in more than $200 billion will be difficult because it would supplant Medicare, which covers the elderly, and the systems that now cover federal employees and retired civil service and military personnel.
A single-payer system also would require Californians now receiving care through employers, unions or public agencies to give up their benefits and join a universal system.
Would they be willing to trust their medical needs to a state government with a sorry record of managing big programs – such as the Employment Development Department and the bullet train project?
Dan Walters has been a journalist for more than 60 years, spending all but a few of those years working for California newspapers.
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