Voting our way to single-payer in California?

THE QUESTION of health care has taken center stage in the high-profile race to be the next governor of California, which will narrow to two in a nonpartisan primary election on June 5.

Donald Trump’s attacks on the Affordable Care Act, combined with rising health care costs, have forced the issue to the fore. With a majority of Californians supporting a single-payer system, the two leading Democratic candidates — current Lt. Gov. and former San Francisco Mayor Gavin Newsom and former Los Angeles Mayor Antonio Villaraigosa — have had to acknowledge the inadequacies of the status quo and put forward visions for the future.

But Villaraigosa has positioned himself as a political “realist” who thinks single-payer won’t work, and Newsom’s maneuverings during the campaign indicate that he is hedging on his stated support for single-payer legislation.

Without a movement to hold the Democrats accountable, both are likely to continue with the party’s pattern — reinforced just last year when Democratic leaders in the state legislature killed a single-payer bill on the verge of passage — of promising to work for health-care justice, but obstructing the only way of achieving it.

A BLUE state through and through, California has a Democratic governor, two Democratic senators and a Democratic majority in both houses of the legislature that stretches back — except for two years in the mid-1990s — to the 1970 election. That’s nearly half a century of Democrats controlling the state house.

Despite the seemingly favorable political context of the “party of the people” in power, California suffers generalized and extreme social inequality, even by U.S. standards.

The United Nations Special Rapporteur on Adequate Housing described homelessness in the state as worse than many other parts of the world. A recent report found that California is the most unequal state in the country, with large gaps between rich and poor in life expectancy, education and income.

Health inequality plagues the state as well. The health care landscape in California is defined by rising costs and diminishing access to care.

The Affordable Care Act expanded health care coverage to about 5 million previously uninsured Californians. However, about 3 million state residents remain uninsured, including 1.8 million undocumented immigrants.

Among insured Californians, an increasing proportion of face high deductibles and premiums that make them more likely to skip necessary care and incur medical debt.

According to a 2016 study, about 21 percent of insured adult Californians were underinsured — meaning their health care “coverage” was skimpy and inadequate. One in four insured adults reported not filling a prescription, not seeing a specialist, skipping recommended tests or treatments, or not visiting a clinic when they had a medical problem.

Last year’s single-payer legislation, known as SB 562, was well on its way to addressing these issues. It passed the state Senate easily, but then stalled in the Assembly, when Democratic Assembly Speaker Anthony Rendon pulled it before it came to a vote.

Rendon claimed that SB 562 had intractable financing flaws. But researchers at the University of Massachusetts Amherst who looked at the fiscal impact of the bill proposed two new taxes — a 2.3 percent gross receipts tax and a 2.3 percent increase in the state sales tax — that would fund the program.

Though a convenient way for Democrats to dodge the issue, costs aren’t what is keeping California from implementing single-payer.

THE DEBATE over SB 562 has re-emerged in the race for governor, arguably the most powerful political position in California.

California has a “top-two primary” system, with candidates for state or congressional office appearing on the same June 5 ballot, regardless of party affiliation. The top two candidates then advance to the November general election.

According to the polls, the frontrunner for June 5 is Lt. Gov. Newsom, followed by Republican John Cox and fellow Democrat Villaraigosa in a close race for second. Fifteen percent of those surveyed were undecided, leaving plenty of room for movement.

Newsom will likely advance to the November elections, but whether he faces a Democrat or Republican challenger remains to be seen, and that will shape the health care debate.

Newsom has begun airing ads that denounce John Cox as an NRA and Trump supporter. His strategy is to prod Republican voters to the polls in the hopes that they push Cox into second place. The political calculus behind this is that Newsom is essentially assured victory if he runs against a Republican in November. His possible Democratic challenger, Villaraigosa, would make for a closer race.

On health care, both Democrats acknowledge that the system in California is failing, and both advocate for an expansion of health care to all residents, regardless of immigration status. But Villaraigosa has remained skeptical of single-payer, calling it “unrealistic”. He advocates for universal coverage through incremental changes such as a public health insurance option — in other words, Obamacare plus the public option.

Newsom has staked out a position to the left of Villaraigosa. His support for SB 562 earned him the endorsement of the California Nurses Association (CNA). Last September, Newsom told the CNA convention in San Francisco: “You have my firm and absolute commitment as your next governor that I will lead the effort to get it done. We will get universal health care.”

While appealing to the liberal base of the Democratic Party, Newsom has left plenty of space to court the party’s big donors, which includes major private insurance companies. Blue Shield of California has contributed about $1 million to independent committees that support Newsom.

SO INSURANCE companies are banking on Newsom despite his rhetorical support for SB 562. They probably have good reason to do so.

Newsom has begun walking back his promise on SB 562 already. In April, he told the San Francisco Chronicle that a single-payer system would take “years” to implement.

He’s also been noncommittal on an explicitly single-payer system, entertaining other methods for achieving universal coverage. In an interview with the Sacramento Bee last year, he said he would be open to a Medicare-for-All model that includes private insurance companies or a universal coverage plan, such as San Francisco’s Healthy SF program, which he approved as mayor in 2006.

Healthy SF made San Francisco the first city in the nation to provide access to health care services to all uninsured residents. A step forward in many ways, Healthy SF is a payer of last resort for San Francisco residents between the ages of 18 and 64 who aren’t eligible for other public programs.

But Healthy SF isn’t an insurance program and adds another layer to the complicated mess of a multi-payer system. The political moment is ripe for a transformative health care fight. There’s no good reason for Newsom to lower the horizons to a state-level version of Healthy SF.

In February, Villaraigosa challenged Newsom to a debate on single-payer in an attempt to paint Newsom as an idealistic liberal and himself as the pragmatic centrist.

Thus far, Newsom has been able to avoid making strong arguments in favor of SB 562. A run against Villaraigosa would force that question back to the fore. On the other hand, in a race against Cox, Newsom could remain more vague about health care.

IN CONTRAST to Newsom’s tepid arguments for single-payer, Gayle McLaughlin’s independent bid for lieutenant governor shows the potential for a dramatically different direction.

McLaughlin is running on a platform that includes support for single-payer, alongside free college, a millionaire’s tax and a ban on fracking.

She’s the former Green Party mayor of Richmond, where she headed the Richmond Progressive Alliance, which brought together independent leftists with progressive Democrats in a sometimes uneasy coalition. Her choice to run for lieutenant governor as a no-party-preference candidate is welcome and could have the effect of prying open electoral space to the left of the Democrats.

McLaughlin faces an uphill battle to make it on the November ballot, with most labor and social movement organizations sticking with the Democratic Party, as evidenced by the CNA’s endorsement of a gubernatorial candidate who takes money from private insurance companies. McLaughlin has not shied away from making the case that a state as wealthy as California has the tax base to fund a single-payer system.

At this point, Newsom seems likely to win on June 5 and again in November. It will be up to single-payer activists then to hold him accountable to his campaign promises.

Political leaders like Newsom will attempt to lower our horizons by putting forward paths to universal coverage other than single-payer. Insurance companies will spend millions on fear campaigns about the cost of single-payer.

But the strong support for Bernie Sanders’s 2016 presidential primary campaign, which focused on health care, and the inspiring activism against the Republican attack on the Affordable Care Act show that the idea of health care as a right is incredibly popular.

A single-payer victory will require mass mobilizations, rallies and strikes. We must figure out what we can do in the here and now to build up the single-payer movement, with an eye toward what it will take to fight and win.