Californians Consider How to Advance Toward Universal Health Care Coverage in an Uncertain Federal Policy Environment

Senate Bill 562 (Lara and Atkins), which would establish a single-payer health care system with universal coverage in California, was approved by the state Senate in early June, but stalled in the Assembly. Although SB 562 will not move forward in 2017, a single-payer proposal could be revived in 2018. This post is the third in a series examining key issues related to the single-payer approach and, more generally, to efforts to move toward universal health care coverage in California. The first post in this series examined whether state policymakers could implement a single-payer system without seeking voter approval, and the second post outlined three principles that should guide efforts to create a single-payer system in California.


Despite the Collapse of the Latest Attempt to Roll Back Health Care Reform, the Federal Health Policy Landscape Remains Volatile

The latest attempt in Congress to repeal the Affordable Care Act (ACA) and drastically cut federal funding for health care — which failed in the US Senate last month — would have devastated California’s health care system. If the Graham-Cassidy bill had become law, our state would have lost billions of dollars in federal health care funding each year, with these losses rising to a projected $53 billion in 2027 alone. These cuts would have pushed an estimated 7.5 million Californians into the ranks of the uninsured, increasing the total number of residents without health coverage to more than 10 million.

Graham-Cassidy’s much-deserved collapse doesn’t mean that California — or the nation as a whole — is out of the woods. Having failed to repeal the ACA through legislation, President Trump has effectively declared war on our nation’s health care system. Last week, for example, Trump issued an executive order to expand the availability of junk insurance, including short-term and bare-bones health insurance plans that fail to meet ACA standards. If implemented, this change “could destabilize health insurance markets” and “make coverage far less affordable for people with pre-existing conditions,” according to an analysis by our colleagues at the Center on Budget and Policy Priorities.

The President also announced last week his intent to stop providing critical payments that help to reduce out-of-pocket costs — such as copays and deductibles — for people with low incomes. (In contrast to the President’s approach, two US Senators recently unveiled a bipartisan deal to fund these “cost-sharing reduction” payments for two more years, although this proposal might lack sufficient support among Republicans to pass both the full Senate and the House.) Ending these payments, which go directly to health insurance companies, would likely “roil” health insurance markets and could undermine the ACA’s stability going forward.

Moreover, Republicans in Congress haven’t thrown in the towel on repealing the ACA and slashing federal funding for Medicaid, which provides health coverage to tens of millions of Americans, including more than 13 million Californians through the Medi-Cal program. In the coming weeks, congressional leaders could advance deep cuts to Medicaid and ACA insurance subsidies in order to offset the cost of their tax cut plan, which would disproportionately benefit the wealthiest households. Republicans also could take another stab at repealing major provisions of the ACA, something they’ve tried and failed to do several times this year.

In Addition to Defending the ACA and Medicaid, California Policymakers and Advocates Are Working to Reimagine the Future of Health Care in the Golden State

Given the volatile federal health care policy landscape, Californians clearly have ample reason to keep a watchful eye on Washington, DC. However, even while California policymakers and advocates are vigorously playing defense on health care reform — fighting to keep the ACA and Medicaid intact — many are also proactively engaged in parallel efforts to reimagine the future of health care in the Golden State. These campaigns and conversations, which are already well under way or set to begin soon, center largely, although not exclusively, on the question of how to move California toward universal coverage, with the single-payer approach clearly among the possible options. These efforts include:

  • A campaign to expand health coverage options for undocumented immigrants in California. In recent years, a number of organizations, including Health Access and the California Immigrant Policy Center, have led a campaign (#Health4All) to extend health coverage to all undocumented immigrants, who comprise a large share of California’s uninsured population. This campaign has already achieved a major policy win: California now allows low-income undocumented children and youth under age 19 to sign up for comprehensive Medi-Cal coverage. (This change took effect in May 2016.) Following on this victory, advocates continue to seek ways to expand health coverage to the many undocumented adults in California who remain uninsured due to their immigration status.
  • Ongoing efforts to advance a single-payer bill through the state Legislature. Senate Bill 562 stalled in the Assembly after Speaker Anthony Rendon criticized it for being “woefully incomplete” and containing “potentially fatal flaws.” Rendon urged the Senate to “fill the holes in SB 562” and send the Assembly “workable legislation that addresses financing, delivery of care, and cost control.” To date, the Senate has shown no interest in revisiting SB 562. Meanwhile, the California Nurses Association (CNA) — the bill’s main proponent — continues to call on the Assembly to move SB 562 forward without further Senate action. Lieutenant Governor Gavin Newsom recently added his voice to this chorus: “It’s time to dust off SB 562” and “move it along the legislative track,” Newsom declared at the CNA’s convention last month.
  • Upcoming hearings in the state Assembly to examine ideas for achieving universal health care in California. This past August, Speaker Rendon announced a series of public hearings that will provide “a new opportunity to determine the best and quickest path forward toward universal health care” in California. These hearings will be convened by the Assembly Select Committee on Health Care Delivery Systems and Universal Coverage, with the first two meetings scheduled for next week (October 23 and 24) in the state Capitol. The committee is charged with examining several options for achieving universal coverage, including — but not limited to — the single-payer approach. This effort “will help fill the void of due diligence that should have been done on SB 562,” according to Rendon.
  • Upcoming forums that aim to develop a “roadmap to guaranteed health care” in California. The California Physicians Alliance (CaPA) has invited experts from around the state to participate in a series of forums that will chart a path toward “a health care system with more efficiency, better outcomes, and greatly increased health equity.” Participants will address several health care-related topics, including how to extend coverage to the uninsured, how to fund a coverage expansion, and whether California can be a national model for a single-payer system. The initial forum will be held in Los Angeles on November 11, with additional meetings planned through May 2018. The roadmap that comes out of this process is intended to “serve as a blueprint for future legislation,” according to CaPA.

No Matter How Californians Choose to Move the State’s Health Care System Forward, Ongoing Federal Support Will Be Vital

Improving California’s health care system could involve a number of changes ranging from incremental reforms to a transformational shakeup. Many changes would be difficult, if not impossible, to accomplish without the cooperation of the federal government. Other reforms could move forward without the need for federal approval or additional federal funding. Regardless of how California decides to proceed, our state clearly needs a supportive partner in Washington, DC — one that is willing to at least maintain the federal health policy framework that has allowed California to make impressive health coverage gains in recent years.

Unfortunately — as described earlier in this post — our national leaders have spent the past several months trying to roll back federal health care funding and policies that benefit millions of people with low and moderate incomes. While proposals to abolish the ACA are on ice — for now — repeal remains a possibility as long as Republicans control Congress and the White House. Moreover, the federal budget plans being advanced by the House and Senate threaten deep cuts to Medicaid funding and ACA insurance subsidies in the years ahead. In the meantime, the President is likely to continue using the powers of the executive branch to undermine federal health care reform.

With the near-term prospects for the ACA and Medicaid so uncertain, Californians must continue to vigorously defend the policy gains that have been made at the national level in recent years, along with the robust federal funding that has made these gains possible. There’s no doubt that Californians can build a better health care system; it’s extremely unlikely that we could do so on the rubble of the ACA.

— Scott Graves