Democratic candidates revive single-payer promise as California's healthcare system faces strain

OAKLAND — When billionaire philanthropist and Democratic candidate for governor Tom Steyer took the stage at a campaign rally Tuesday with the powerful California Nurses Association, he promised to deliver one of the union's top policy goals: universal healthcare for Californians.

"I will die on this hill," Steyer said to wild applause.

He's not the only Democrat pledging single-payer healthcare, a form of universal coverage and a progressive rallying cry, as candidates court voters ahead of the June 2 primary election. Former U.S. Rep. Katie Porter and California state Superintendent of Public Instruction Tony Thurmond have made that promise as well.

In reality, Democratic lawmakers in Sacramento have repeatedly rejected the idea, which would replace most private health insurance with a single payer: the state of California.

"It's like the central issue in Democratic primaries in this generation," said UC San Diego political science professor Thad Kousser, "but it's not become a central issue in any Democratic administration — whether that was Gavin Newsom in California or Joe Biden in Washington, DC."

Like candidates this year, Gov. Gavin Newsom was a staunch supporter of single-payer healthcare when he first ran for the office in 2018. That helped him shore up support from Democrats angry and anxious about healthcare costs.

But Democratic lawmakers, who controlled the state legislature for all of Newsom's tenure as governor, killed three universal healthcare bills in that time over concerns about its huge cost — with the most recent blow coming last month.

With steep cuts to federal funding for Medi-Cal expected in the next fiscal year, as part of President Donald Trump's "Big, Beautiful Bill" passed by Congress in 2025, Newsom and state lawmakers have focused on shoring up California's fractured healthcare system.

About 3.5 million residents could lose their eligibility for Medi-Cal, the state's version of Medicaid, which provides free or low-cost health insurance for low-income residents and people with disabilities.

In the Bay Area, that's a major fiscal challenge for health systems. With those and other federal cuts to health spending under Trump, recent polls show Californians worry more about surprise medical bills than any other household expense.

A UC Berkeley analysis this year projected CalCare, the proposed single-payer system, would cost $731 billion each year, plus $110 billion needed in reserves. Federal funding would account for a quarter of the cost. However, experts also expect that administrative efficiencies would drive massive cost savings in the long term.

Advocates of single-payer in California note the U.S. is one of the few industrialized countries without universal healthcare. The nation's fractured system is associated with worse health outcomes and barriers to care, according to the nonprofit health analyst group KFF.

Countries have different versions of single-payer healthcare, including Canada and Taiwan. In Canada, residents pay for care via taxes. Its system ranks above the U.S., but still poorly due to low access to care and health outcomes. Taiwan's single-payer system covers every resident and is mostly funded with premiums paid by individuals and businesses. Patients still have to pay out-of-pocket expenses, but the island nation spends far less on healthcare than the U.S.

In California, single-payer is fiercely opposed by health insurers, the California Medical Association, chambers of commerce and a laundry list of industry trade associations. The nurses' union and some physician groups have supported it.

Adding to the uphill battle for advocates: To help pay for single-payer healthcare, the federal government would need to allow California to repurpose federal funds for Medi-Cal, the state version of Medicaid, and other health programs. President Donald Trump's Republican administration would almost certainly refuse to do so.

This spring, San Jose Assemblymember Ash Kalra's Guaranteed Health Care for All Act died in the statehouse without a hearing — or even an assignment to a policy committee, the first step in the process from bill to law.

"I'm disappointed. I and the nurses have been working on this for many years," he told this news organization. "We're going to keep pushing it."

That bill would have established CalCare, a single source of health insurance covering citizens and residents without legal status, without premiums, deductibles or copays. Kalra's office said patients could keep their doctors as well.

Kalra tried to pass similar bills in 2022 and 2024. He wasn't able to rally enough support from his Democratic colleagues, largely because of the price tag.

As governor, Newsom moved toward an incremental expansion of existing healthcare tools, rather than the complete overhaul he campaigned on in 2018. He has focused instead on extending private and public health insurance coverage to more residents, in part by expanding Medi-Cal. His administration made progress in slashing the number of people without coverage.

Even if single-payer healthcare is a long shot, Kousser, the political scientist, said there are still strategic reasons for gubernatorial candidates to make the promise this year. For example, Steyer has scooped up the endorsement of the powerful nurses association, whose leaders vowed Tuesday to campaign hard for the billionaire ex-hedge fund manager.

But not all Democratic candidates support single-payer, which remains divisive between moderates and members of the party's progressive wing, who have historically supported the initiative. That dynamic was laid bare in Tuesday's gubernatorial debate.

Former U.S. Health Secretary Xavier Becerra, who recently emerged as a frontrunner in the race, said as recently as last month that he supported single-payer healthcare. But KQED reported last week that he distanced himself from the policy when he secured the endorsement of the influential California Medical Association — a key opponent of single-payer. The association also made a maximum $39,200 donation to Becerra's campaign this week.

Becerra called KQED's report "inaccurate" at a debate hosted Tuesday by CNN and said he has been consistent in his support for Medicare for All, a federal single-payer system, over the last three decades. But when Porter pressed the former secretary on whether he'd specifically support CalCare, Becerra deflected, refusing to give a yes or no answer and reiterating his support for Medicare for All.

A spokesperson for Becerra also didn't answer when a reporter asked for his position on single-payer healthcare.

"Xavier Becerra's position on this issue has never changed," spokesperson Jonathan Underland said in an email. "As Governor, he will continue the work he started through building the Affordable Care Act to ensure every Californian has access to affordable, high-quality health care."

While the candidates slam each other over universal health coverage, they're offering few details about how to make single-payer healthcare a reality.

Porter's campaign did not respond to a request for comment on how she would pay for CalCare. Her website claims that single payer would "save California billions in healthcare costs every year."

Steyer also dodged questions about financing the idea at Tuesday's rally. Elsewhere, he has pledged to close a corporate tax loophole worth about $20 billion annually, nowhere near the projected cost.

That didn't seem to matter at the rally on Tuesday, where nurses leapt to their feet to give Steyer a standing ovation.

"We're going to do all that we can to get Tom elected," union president Sandy Reding said.

California's history of single-payer healthcare legislation

The campaign pledge for healthcare for all, funded by the state, hasn't gotten far in Sacramento:

September 2017:

Newsom was a big supporter on the campaign trail. He tweeted, "I'm tired of politicians saying they support single payer but that it's too soon, too expensive or someone else's problem," Newsom tweeted.Single payer passed the state Senate, without a way to pay for it; California Assembly Speaker Anthony Rendon held the bill back for that reason, drawing the ire of supporters.

2022:

Kalra's AB 1400, which would have created a state-based single-payer system, died without a hearing. Staunchly opposed by the Chamber of Commerce, health insurers, and doctors and hospitals associations. The chamber vows to oppose the idea in the future, too.

2024:

A bill creating California single-payer dies in the Appropriations Committee. It pitted two Bay Area lawmakers against each other. Buffy Wicks (D-Oakland), chair of the committee. "There were some tough choices to make," she told the LA Times.

2026:

Kalra's CalCare bill, AB 1900, fails to move forward again.