Whither Single Payer?
Sacramento single payer demonstration in 2021 (photo Angela Hart/California Healthline)
Over the next few weeks, California Assemblymember Ash Kalra (D-25) is expected to unveil the latest iteration of CalCare, a state single payer bill drafted by the California Nurses Association. Kalra’s last effort, AB 1400, cleared the Assembly Health Committee, only to be withdrawn when it became obvious that there was not enough support on the Assembly floor. Will this one fare better?
Few would deny that our health care system is not working. COVID 19 exposed many of its most egregious failures, not the least of them a mortality rate during the pandemic that was two to three times as high in black and brown communities. Prices keep skyrocketing, access to providers is difficult for many, medical bills remain the leading cause of personal bankruptcy. Nationally, two-thirds of all working age adults experience medical debt.
Broad public support for single payer
Poll after poll has shown broad public support for single payer. A recent study by the UC Berkeley Labor Center projected massive savings under a system of unified public financing—enough to cover a costly but badly needed long-term care benefit and still spend less than we’re spending now.
But getting the politicians to act has been an uphill battle. In 2006 and 2008, single payer bills passed both houses of the state legislature, only to be vetoed by then-governor Schwarzenegger. Another bill, SB 562, cleared the Senate in 2017; Assembly Speaker Rendon refused to allow a floor vote, most likely to shield Governor Jerry Brown from the kickback of an anticipated veto.
Our current governor, Gavin Newsom, ran as a single payer candidate in 2018. Though hardly a reliable ally, he has at least made a commitment and knows the political cost of betraying it. With the defeat of AB 1400 eighteen months ago, it was the Legislature that got cold feet. Perhaps more troubling, there was a noticeable falling off of active support from organized labor, the one force with the resources and lobbying clout to counter the private health care industry.
A love-hate relationship with Kaiser
Union misgivings resulted from a significant change in the language of AB 1400. One Californian in four gets medical care from Kaiser, a health maintenance organization (HMO) that has collective bargaining agreements with tens of thousands of union members. Kaiser’s 9.6 million members in California are apt to have a love-hate relationship with Kaiser: people appreciate its model of integrated health care, but often get less than satisfactory treatment if their particular ailments are costly to treat.
Earlier single payer bills tried to prevent such abuses by removing market incentives to discriminate: first, by allowing everyone, not just members, to be treated at Kaiser, and second, by enforcing uniform standards of care for all health care providers. But CNA has concluded that capitation—paying providers based on how many patients they treat—is inherently discriminatory, since it rewards those whose patients are healthier and effectively penalizes those whose patients are sicker. AB 1400 barred capitation and removed the language from earlier bills that spelled out ground rules for integrated care systems. Since capitation is a big part of the Kaiser system, some wondered whether Kaiser would continue to exist if AB 1400 passed.
Whether or not such concerns were justified, they clearly need to be addressed if we are to build a movement strong enough to win. Partly toward that end, Healthy California Now, the state single payer coalition that California DSA recently joined, pushed SB 770 through the Legislature last year. SB 770 seeks to remove both legal and political barriers to passage of single payer legislation—first, by getting around the various federal rules that might hinder implementation of a state plan; second, by involving a broader range of labor and health care activist forces in drafting a new bill.
Internal conflict in the single payer coalition
CNA actively opposed SB 770, arguing that it was unnecessary at best and, at worst, a cynical effort to derail CalCare. Ash Kalra, an early supporter, changed his mind and came out against it. Some CalCare partisans have gone farther, launching bitter internal fights in both Health Care for All-California and Physicians for a National Health Program.
Both organizations are longtime bulwarks of the state single payer movement. Both worked for AB 1400. But they were now excoriated for their support of SB 770 and their continued participation in Healthy California Now. When they declined to change course, the critics broke away and formed their own organizations.
Whatever motivates this internecine conflict, it’s worth noting that it began as a difference of opinion among policy experts over whether paying health care providers through capitation is acceptable under a single payer system. But most Californians probably aren’t particular about how their doctors are paid, so long as they get the care they need.
Single payer advocates sometimes talk as if the abuses of capitalist health care could be corrected if only we enacted the proper structural reforms, getting the details right and shunning compromise. But state single payer legislation is already a compromise: federal legislation would clearly be preferable. A national health plan, making delivery as well as financing of health care a public responsibility, would be even better. Even that requires a vigilant, organized public to make sure it does what it’s supposed to.
In California, the potential is there. Already, a coalition of health care activists and immigrant rights advocates has succeeded in winning full MediCal coverage for all undocumented people. DSA-Los Angeles member David Monkawa, who was active in that campaign, argues that “the single payer movement must recognize and fight for immediate reforms as a basis for unity.” Writing a perfect bill counts for little if we haven’t developed an effective strategy and built a movement that unites all who struggle for health care justice.