California’s next governor Gavin Newsom is an avowed single-payer supporter in the country’s most populous state. But how much of his stand is principle and how much is policy is not totally clear. And no matter how he handles it, he’ll inevitably anger part of his base.
That, in a nutshell, is a preview of the Democrats’ health policy dilemma heading into the 2020 election cycle. Single payer, or “Medicare for All,” has become a litmus test for the growing number of Democrats who are contemplating challenging President Donald Trump. Newsom’s stance gives supporters some cover, turning the issue mainstream. But making good on the promise carries big risk — even for a politician who won by a nearly 20-point margin.
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The midterms showed the potential perils of embracing single payer. Republicans and the Trump administration attacked it as “socialized medicine.” And though some high profile candidates likes Reps.-elect Alexandria Ocasio-Cortez of New York and Ayanna Pressley of Massachusetts rode support for the idea right into Congress, others like Beto O’Rourke in the Texas Senate race fell short. A number of likely Democratic presidential contenders — Sens. Kamala Harris of California, Cory Booker of New Jersey and Elizabeth Warren of Massachusetts — have signed on to Sen. Bernie Sanders’ Medicare for All legislation.
Nobody expects Newsom to enact single payer in the first two years of his term. He’s tempered expectations but says he remains committed to expanding coverage while finding a pathway to a government-run system that could serve as a blueprint. Part of his early policy agenda is expected to include making California the first state to expand Medicaid to undocumented immigrants.
“Since he has promised so much, and since he has talked about California as national model and since he’s going to be the principal architect against President Trump from ‘Left Coast,’ anything he does on health care — managed care, Medicare for All or something in between — will serve as a model to catapult him into the national conversation,” said David McCuan, a strategist who teaches political science at Sonoma State University.
The question is whether an incremental, go-slow approach will gradually rile progressives eager for big change. On the other hand, a bolder effort will force sticky policy questions. Single-payer legislation failed to move in the state Assembly in 2017 and died this year; a state analysis found it would cost $400 billion, half of which would come from new taxes.
“If he can show progress on keeping his campaign promises, I think people understand changing and improving the health system takes time,” said Ian Russell, a political strategist and former Democratic Congressional Campaign Committee official. “I would assume he’d want to keep California at the forefront of showing a different way of governing than the [Trump] administration, by bringing down the costs of health care and increasing access to it, but it’s more important he take the time to get it right.”
Extending health coverage regardless of immigration status would in itself be reminiscent of the precedent-shattering move Newsom made after being elected San Francisco mayor in 2004, when he started issuing same-sex marriage licenses. Covering undocumented immigrants would put California in the direct line of fire of the Trump administration.
“In a time when you have an administration that’s incredibly negative toward the undocumented community, it will seem incredibly courageous,” said Robert Blendon, professor of health policy and political analysis at Harvard’s T.H. Chan School of Public Health. “And it will probably get [Newsom] into a suit with the government, which he will love.”
Newsom’s power to endorse candidates who support single payer shouldn’t be underestimated, Blendon added. “When people say they’re too extreme, too liberal, too socialized, you’ll have the governor in the largest state who agrees with them,” he said.
Still, anything short of single-payer health care will put Newsom at odds with true supporters of a government-run health care — namely the politically powerful California Nurses Association.
The registered nurses union, the primary backers of California’s failed single-payer initiative, endorsed Newsom and say they’ll hold him to his words.
Stephanie Roberson, director of government relations for the union, said Newsom “didn’t wait for the whole marriage equality piece” before issuing marriage licenses, and called the universal health access program enacted in San Francisco under his watch “a microcosm of what we’re trying to get to.”
“He has the courageousness and know-how to be set up to get this done,” Roberson said.
Most observers still expect Newsom to initially take a piecemeal approach and devote more state money to making coverage more affordable while also addressing prescription drug prices and strengthening California’s health care marketplaces.
“The job for the Newsom administration is to build on what’s working,” said Peter Lee, executive director of the state exchange, Covered California. “He understands health care is a complex issue and … he’s going to make progress on what’s already working in California.”
Newsom is seen as far more interested in health care than his predecessor, Democrat Jerry Brown, and health care groups are jockeying to influence his new administration.
More than 50 consumer and labor groups gathered a few days after the midterms to map out next year’s state legislative agenda. Most participated in the Care4All California coalition, formed in March to push for legislation to expand and improve health care in the state without the need for federal approvals.
Making plans so soon after votes were cast “speaks to the seriousness and interest in moving this agenda early in the new year with a new governor,” said Anthony Wright, head of Health Access California and a leader of the coalition.
The nurses union did not participate in the coalition but has already announced it will be backing a new single-payer bill in the upcoming session.
The union’s Roberson said the nurses also support such moves as extending coverage to the undocumented. “We would be upset if that’s the end of the road for him,” she said. “As the ultimate solution? It is single payer.”