People who don’t follow health care politics closely might believe that Medicare For All is an idea coined by Bernie Sanders’ presidential campaign in 2016. In fact, the idea goes back to 1965, when Medicare was created. The people who set up the program, according to a 2019 Time magazine overview, envisioned it as the first step toward a universal government-funded health program. Or, you could say it goes back thirty years before that, when Franklin Roosevelt proposed adding health coverage to the Social Security Act of 1935.
In 1947, Harry Truman tried to establish national health care financed by the federal government through a payroll tax, in what became the Wagner-Murray-Dingell Bill. The American Medical Association went on the offensive to kill the bill, stoking fears that “physicians, dentists, nurses and medical technicians” would “become … servant[s] of a government agency taking orders from a departmental bureaucrat” and branding the not-that-liberal Truman a closet socialist. The AMA hired a public relations firm to wage a propaganda campaign, and successfully prevented the bill even from coming up for a vote.
The Sad Tale of Proposition 186
The California Health Security Act, Proposition 186, was placed on the California ballot in 1994. The initiative was sponsored by a coalition led by a San Francisco grassroots organizing group called Neighbor-to-Neighbor. The activists quickly gathered over a million signatures to get the initiative on the ballot. More impressively, sixty percent of those signatures were gathered by volunteer canvassers, something virtually unheard of now, when nearly all successful initiative campaigns employ paid signature gatherers. Unfortunately, that was the high point of the organizing campaign. To the great disappointment of activists, including LAGAI members who beat the pavements to encourage people to vote for single payer health care, 186 lost overwhelmingly, with just over a quarter of voters voting yes.
Part of what doomed Proposition 186 was its timing. It was on the same ballot as Proposition 187, a broad anti-immigrant measure, and the Three Strikes Initiative (Proposition 184), which enabled many people to be locked up for life for minor crimes, and contributed a lot to California’s mass incarceration explosion. Both of those were much higher profile than 186. Latinx and Asian organizations were more focused on 187, while the Black community and youth organizations were working hard to stop Three Strikes (the substance of the initiative had already been adopted by the legislature and signed into law but the initiative meant that it couldn’t be undone by a future legislature). With the exception of a few left-led coalitions, there was not that much crossover between the two groups, and neither of them had strong ties with the groups promoting single payer, primarily labor unions and the senior sector, who hired an all-white staff to direct the campaign.
The Prop 186 campaign was further hindered by the fact that the O.J. Simpson case had led major news outfits to pare down their electoral coverage, and there were also highly contested gubernatorial and Senate races (it was the first Senate race after the Anita Hill/Clarence Thomas hearings in 1991 and dianne feinstein and barbara boxer were elected as the first women Senators from California). What little mainstream media coverage the single payer campaign got was negative, and focused on how much it would cost, despite the nonpartisan legislative analyst’s projection that the long-term impact on the state’s finances would be neutral or positive. According to a thorough and interesting analysis by Peter Dreier and Matthew Glasser in the journal Social Policy, the campaign did not produce any data or stories to effectively counter the negative messaging put out by the media and the $10 billion corporate opposition.
Propositions 187 passed with 59% of the vote, evil republikkkan pete wilson was reelected governor with about 55%, and Three Strikes passed with over 71%. So a simpler explanation for Proposition 186’s failure could be that it was just a very mean-spirited time in our beloved state. Which I can attest that it was.
Another issue identified by Dreier and Glasser was that in 1994, the clinton administration was embroiled in trying to create some type of universal coverage plan that could get through congress. (Monica Lewinsky and stained dresses had not yet taken over the airwaves.) A lot of California voters, they suggest, thought the problem (of unaffordable or unavailable health coverage) was going to be taken care of at the federal level. Moreover, active or identified Democrats were wary of anything that might look like it was seeking to undermine the administration’s efforts. The same problem would rear its head in 2012, when state Democrats worried that any effort to pass statewide single payer would look like disloyalty to obama and the embattled Affordable Care Act.
In between those two polar events, a labor-led coalition called Health Care for All-California (HCA) spent many years scheming and dreaming. One plan to get a single payer bill introduced in the Assembly stalled when the specially selected author of the bill, Barbara Lee, was bumped up to Congressional Representative after Ron Dellums abruptly retired. In 1999, the Senate passed, and governor gray davis signed, SB480, which called for a study process followed by the “enactment” of universal health care for all Californians. The catch: language setting a “date certain” for such care to be established was removed as a condition of its passage. The result was a series of studies, studies and more studies, the Universal Health Care Technical Advisory Committee (UHCTAC) and the California Health Care Options Project (Cal-HCOP). When you see that many acronyms, you know nothing good is going to happen.
However, in 2006, the California legislature became the first in the country to pass a bill calling for single-payer health care. governator arnold schwarzenegger, who grew up in a country with national health care, vetoed it, calling it “socialized medicine” in an op-ed. After a year-long direct action campaign by labor and community organizations, the legislature passed a second bill in 2008. The governator vetoed it again.
Long and Winding Road
In 2018, the state senate passed SB 562. It was a really good bill, mostly written by the California Nurses Association (CNA), calling for universal coverage for all California residents, regardless of immigration status, age or any other demographic distinctions. It would eliminate private health insurance, expand the current care offered under Medicare and Medicaid (Medi-Cal) to include dental, vision, mental health, substance abuse treatment and long-term home care. All current subsidies from federal and state sources, such as Medicare, Medicaid and ACA subsidies, would be bundled and used to provide treatment under the program. Since 70% of current health care spending is currently funded through federal or state programs, that leaves only 30% to be funded through a Health Care Trust, which would have to be funded through taxes. The taxing mechanism was not specified in the bill, and assembly speaker anthony rendon used that lack of specificity as a reason to table the bill, saying it wasn’t ready to be voted on. Many people suspected that rendon was taking the fall for outgoing governor jerry brown, who had once supported single payer but had since backtracked and maybe didn’t want one of his final acts to be vetoing something supported by the unions that had helped elect him.
gavin newsom was elected governor in November 2018, with strong support from CNA. Newsom, who claims credit for the “Healthy San Francisco” program enacted while he was mayor, promised CNA “you have my firm and absolute commitment as your next Governor that I will lead the effort to get [single payer] done … have universal healthcare in the state of California.” When he took office in January 2019, he immediately wrote to the white house and congressional leaders, asking for a waiver that would allow California to use ACA subsidies to establish a single payer system. He never got a response from the white house.
Bernie Sanders’ presidential campaign, along with outspoken members of the congressional progressive caucus including Pramilla Jayapal, who introduced the Medicare For All Act in the house, and Alexandria Ocasio Cortez who rules Twitter, helped make “Medicare for All” a litmus test in the 2020 primaries. In an April 2020 poll by The Hill newspaper, 69% of registered voters supported “providing medicare to every American,” and that included 49% of republikkkans.
A recent Kaiser Foundation poll found that 87% of Democrats supported “Medicare for All” but only 64% supported “single payer health care.” And therein lies part of the rub.
The idea of calling a single-payer health care delivery system “Medicare for All” came from a former staffer to Ted Kennedy, who championed the idea from 1974 until he died in 2009. Philip Caper, according to Pro Publica, told Kennedy in the early 2000s that “single payer … was too wonky, and no one knew what it meant.” Medicare was popular and people knew what it was. You didn’t have to waste time explaining it. Except …
Mention Medicare For All (M4A) to anyone currently on Medicare and the first thing you’re likely to hear is a rant about how terrible Medicare is. Though still popular, it’s been eroded considerably since the Reagan years, and new enrollees are frequently shocked by the cost, complex rules, and in some areas, scarcity of providers. At the same time, the right wing is busy telling seniors, who are less supportive of single payer in general than younger voters, that M4A will “eliminate Medicare” when in fact, the proposed bills would make it much better.
The bill first introduced by the late John Conyers in the house in 2003 was called the “Expanded and Improved Medicare for All Act.” Jayapal’s bill and its companion in the Senate, introduced by Sanders, would cover a lot of things that Medicare does not currently cover and eliminate copays, donut holes, prescription fees and other loopholes. No more Part D or Part B. No more Medicare vs. Medicaid vs. ACA coverage.
Back to the Future?
joe biden famously promised to veto any Medicare For All bill that made it to his desk. However, his pick for health & human services secretary, Xavier Becerra, is on record as a strong supporter of M4A. According to the New York Times, if confirmed, he would have the power to grant waivers to enable states to transition to single payer if they wanted to. A coalition of about fifty labor and community organizations called Healthy California Now is preparing to launch a campaign to pressure newsom to ask for such a waiver as soon as biden takes office.
Though it might seem like this shouldn’t be a tough win, given newsom’s promises to fight like hell for single payer, he’s not exactly a model of integrity. Some people in the know seem to suspect that he only asked the current administration for the waiver because he knew he wouldn’t get it and that he might balk if he thinks he might actually have to implement single payer. He’s made noises in the last year about not doing anything during the COVID-induced recession, and in fact, a pandemic is not the ideal time to contemplate huge changes to the state’s health care infrastructure. On the other hand, COVID has made it more than clear how inadequate our current system is and how badly we need something better.
Democratic Socialists of America has taken the lead on preparing a petition to newsom demanding that he ask for the waiver. The petition will launch on January 7 and we’ll be trying to get a minimum of 25,000 signatures before inauguration day. All the member groups of Healthy California Now (HCN) will be pushing their members to sign and share it. DSA is planning a wide range of actions to build interest and spread the word, from short videos of people from different constituencies telling their stories, to press conferences with art actions to phone banking and possibly in-person canvassing (some members feel that canvassing during the current COVID surge and shutdown sends a bad message, even though it can be done with proper distancing protocols).
HCN is also working with legislators to reintroduce SB562, or a new version of it. This one will hopefully solve the funding mechanism issue, which remains thorny. One problem is that Proposition 98, passed by the voters in 1988, mandates that 40% of the state’s budget go to schools. So if, as the 2017 analysts assessed, the new health system required an increase to the state’s budget of $106 billion annually, the new taxes would need to raise $150 billion. The other problem, probably the bigger one, is that people just don’t like new taxes. Even though for most people health care spending would decrease, that would not be true immediately, and people like immediate gratification.
About 45% of Californians get health insurance through their employers. I asked in our DSA committee what would happen to those folks (of which I’m one) under the single payer plan and was told, it’ll all be good, don’t worry about it. But I do worry about it because I think my coworkers would squawk if they see a 15% tax increase (one number I have seen, although there are other, much lower figures thrown around), we lose our company-provided health benefits and our wages don’t go up. While the union-produced fact sheet I was referred to suggested that “money saved from lower healthcare costs could go to wages and other employee benefits,” there’s no guarantee of that. In nonunionized workplaces with employees in many states, like mine, it’s pretty unlikely that employers will want to have two different wage scales for the same positions, one for California and one for everywhere else. I did find one thing that says, “Employers would still be able to pick up 100% of payroll premiums,” and that seems plausible – that instead of paying my premium to Blue Cross, my work pays into the California Health Care Trust on my behalf. But that’s actually the first thing I’ve seen that suggests we’re talking about a payroll tax; the previous plan called for a gross receipts tax on businesses, and a sales tax with some kind of income-based tax credit – not a good idea, if you ask me, but no one is.
Right now, California groups are using the “Medicare For All” language to capitalize on its name recognition, but hopefully we will soon transition to something like CalCare. Medicare is a limited federal program, and what we’re talking about is really different, so we just waste time trying to explain that this M4A really has nothing to do with Medicare.
Although HCN has a great statement on its website calling for abolition of policing as we know it, defunding the police, and recognizing racism as a health risk, the ties between M4A and California single payer advocates and racial justice groups, especially Black organizations, are still weak. Groups like Movement for Black Lives, Alliance of California Communities for Empowerment (ACCE) and Black Youth Organizing Project have endorsed the campaign, but are not prioritizing it in their own organizing. As one organizer said, “When Black folks hear ‘for all,’ we know that doesn’t mean us.” The good news is that HCN understands this and is working to create the relationships needed to win single payer in California. Check out their “Report and Strategic Recommendations” at https://healthyca.org/get-involved/california-single-payer-report-and-strategic-recommendations/.
Get involved. Get info at healthyca.org or consider joining DSA’s Medicare 4 All committee wherever you live (dsausa.org). Or if there isn’t a chapter (maybe in your prison?), start one! (Write to email@example.com or Democratic Socialists of America, PO Box 1038, New York, NY 10272.)
Look for the petition to newsom on January 7 wherever you get your news (it’ll be on Action Network). Sign it and send it to ten friends.
One in eight U.S. residents lives in California. As we go, so go New York, Washington and no doubt, Austin, Texas.
We are unstoppable. #HealthyCANow!