For California Democrats, single-payer health care is back. Voters have heard it before

California Democratic candidates for governor can’t stop talking about single-payer health care — again. 

The idea of a government-run universal health care program that would replace private insurance as the sole payer of health care costs faces as many headwinds as ever. It had fallen onto the backburner after Gov. Gavin Newsom and Democratic lawmakers failed to get it done, with some balking at the $392 billion estimated annual cost. 

Health advocates have since turned their focus to the impending Trump administration cuts to Medi-Cal, the state’s expanded government health coverage for low-income residents. Even so, the progressive rallying cry of “Medicare for All” has become a staple of Democratic platforms. Few of them offer any specifics on how they would make it happen.

Climate activist and Democratic gubernatorial candidate Tom Steyer was opposed to single payer when he briefly ran for president in 2020, but changed his mind in December. The billionaire candidate told party delegates at their convention last month that because he is not beholden to corporate interests, “I can state the simple fact that we need a single-payer health care system in California.” 

Former Orange County U.S. Rep. Katie Porter endorsed the policy in a video and declared to party delegates that as governor, she would “deliver single-payer health care.” Porter, a longtime single-payer supporter in the past, had declined to commit to the issue last year over feasibility concerns, telling Politico she didn’t think the idea was “realistic in the next couple of years.” 

State Superintendent of Public Instruction Tony Thurmond, former Controller Betty Yee and former U.S. Health and Human Services Secretary Xavier Becerra have all also said they support it. 

Bay Area Rep. Eric Swalwell, who polls show is statistically tied for lead in the race with Porter, Steyer and Republican frontrunners Steve Hilton and Chad Bianco, would focus instead on creating a public option, a spokesperson said, an alternative that attempts to lower costs by creating a state-run plan to compete with private insurance. That model is a more moderate approach because it aims to provide a more affordable coverage option but allows employers to keep their private coverage if they choose to. 

Newsom’s unfulfilled promise

Setting up single payer in California would require the federal government’s approval for the state to repurpose federal dollars that currently pay for Medicare, Medicaid and veterans’ health coverage, which the Trump administration would almost certainly deny. It would also likely require a hefty state tax hike, though advocates say it would save the state money in the long run in lower drug prices and administrative savings, and save Californians out-of-pocket costs. 

David Panush, a consultant who worked on health care policy in the Legislature for two decades, said those two factors make him believe the perennial Democratic promises to establish single-payer healthcare are usually merely “aspirational.” 

“It’s easy to make promises,” he said. “We all want to see the plan.”

Plus, California is in a budget deficit for the fourth year in a row, and its existing public health care programs face immediate peril from Trump administration cuts. More than 500,000 Californians are expected to lose Medi-Cal coverage this year, rising to 1.8 million in the future, and hundreds of thousands of others are expected to lose coverage through the Covered California marketplace after federal premium subsidies expired last year.

Advocates for a single-payer system like Rachel Linn Gish, spokesperson for the consumer group Health Access California, say it’s “inevitable” that it’s part of gubernatorial candidates’ platforms. But she is not particularly hopeful about its short-term prospects. Though advocates want to see single payer in the long term, she said, “we also want to see short-term solutions: how (candidates are) going to start on Day One to protect Medi-Cal, Covered California, coverage for immigrants and LGBTQ care.”

“Sometimes it feels like single-payer is the future health system of California, and always will be,” said Daniel Zingale, a former strategic adviser to Gov. Gavin Newsom, who famously ran on the issue. 

During his 2017 campaign for governor, Newsom said Californians had “my firm and absolute commitment, as your next governor, that I will lead the effort to get it done.” The stance secured him the endorsement of the California Nurses Association, but it remains one of Newsom’s biggest unfulfilled promises. 

The governor launched a commission in 2018 to study single payer and asked for a federal waiver to allow it, which was a nonstarter with the first Trump administration. Since then, he has passed on supporting any of the nurses’ union’s efforts. 

Democratic lawmakers, too, have failed to bring the issue close to his desk, with one attempt flaring out in public in 2022 after Assemblymember Ash Kalra, a San Jose Democrat, couldn’t muster enough legislative support and didn’t want to alienate colleagues by forcing them to take a vote. He tried again in 2024, but lawmakers killed it before it reached the Assembly floor.

Over the past eight years, Newsom has shifted his strategy to instead address “universal access” to health care by providing subsidies for Covered California and gradually expanding Medi-Cal to cover some undocumented immigrants. It has resulted in more than 94% of the state’s residents having health insurance, a practical effect that advocates like Health Access applaud despite their long-term support for single payer. 

And Newsom’s administration has made some smaller moves toward single payer, with the governor in 2023 signing a law requiring the state to research the kinds of waivers it would need from the federal government. A public report on the issue was due in November but has not yet been released. 

The idea has always put progressive Democrats at odds with powerful private interests such as insurers, hospitals, doctors and the California Chamber of Commerce, which generally opposes tax increases, wants to preserve employers’ choice of insurance companies and doesn’t want the state to spend on “a new, unwieldy government bureaucracy,” said spokesperson John Myers.

Why single payer keeps failing

Now, with Newsom termed out and leaving office at the end of this year, those running to replace him are picking up the same big promises. The same groups are opposed. 

“There’s a reason that similar proposals have failed to gain traction in the past: The effort is more symbolic than serious,” Myers said.

Democrats pushing for single payer are unfazed. A spokesperson for Porter did not respond when asked how she would get single payer done despite past failed attempts. As for Steyer, spokesperson Danni Wang wrote in a statement that “he knows the fight won’t be easy” against “Washington politicians and corporate interests that profit from high health care costs.”

Steyer’s campaign supports the policy outlined in Kalra’s bill, which the lawmaker reintroduced this year. The bill would have the state take over the role of private insurance with every Californian eligible for coverage, and require the state to seek federal waivers to help fund the program. As for state funding, the bill states the Legislature will come up with the revenue after the policy is set up. 

Kalra has endorsed Steyer along with the nurses’ union. He dismissed criticism that he hasn’t included a state funding source, saying the state must set up the policy before then waiting for a friendlier federal administration to request a waiver to help fund it.

“We can do two things at the same time, we can push back against Trump and the Republican cuts to health care by taking immediate actions to help ensure Californians still have access to health care, and start to chart a path on what we want to see after Trump,” he said. 

With premiums rising every year, “it seems like almost a softball when it comes to Democratic politics at this time … to at least sincerely explore the support of it.”