As the race for governor heats up, support for a government-run single-payer health care system is becoming a kind of litmus test for Democrats -- and no candidate has embraced the idea more closely than Lt. Gov. Gavin Newsom.
But pressure to support single payer, including SB 562 which passed the state Senate before stalling in the Assembly, has gotten the attention of candidates up and down the ballot, some of whom fear alienating the powerful "take no prisoners" California Nurses Association, single payer's most ardent supporter.
Newsom has long been a favorite of the nurses union. In fact, they endorsed him for governor more than two years ago, in large measure based on his support for Healthy San Francisco (HSF), a program enacted in 2006 when he was mayor.
The idea was first proposed by then-Supervisor Tom Ammiano, a frequent critic of Newsom's. The former mayor acknowledges that he had serious questions and doubts about the idea when it first surfaced, partly because small businesses were required to help pay for it. Among its biggest critics was the Golden Gate Restaurant Association, which sued in federal court to stop it.
Newsom, himself a restaurant owner, eventually came around, and now he uses HSF to tout his credibility on single payer. Enacted before the Affordable Care Act (ACA), or Obamacare, Healthy San Francisco was intended to provide "universal access" to health care for low-income folks who did not otherwise qualify for Medi-Cal.
At a convention of nurses in September, Newsom bragged that the program greatly expanded the city's health care safety net, "regardless of pre-existing conditions, regardless of your ability to pay and regardless of your immigration status -- the only city with universal health care."
According to the San Francisco Public Health Department, at its peak in 2010, HSF had just under 57,000 members at a cost of about $100 million. It wasn't insurance, but rather a connection for members to a primary care physician and a "medical home" where they could get treatment, so they didn't have to rely on costly hospital emergency rooms.
Since the ACA took effect in 2011, most enrollees of Healthy S.F. have transitioned into Covered California, the state's version of Obamacare with expanded eligibility for Medi-Cal. Today, Healthy San Francisco has just over 10,000 members.
Newsom insists his support of that program shows he can deliver single-payer health care to California if he is elected governor.
But his closest rival in the race, former Los Angeles Mayor Antonio Villaraigosa, says Newsom is promising something he can't deliver.
"Am I for single payer?" Villaraigosa asked rhetorically at a recent debate in Los Angeles. "I'm philosophically for it. But we gotta address the fact that it costs $400 billion. And anybody who's telling you we should do it without a plan is selling you snake oil."
Newsom had a tart reply to Villaraigosa at the Democratic Party Convention last weekend.
"My opponents, they call it snake oil," Newsom said. "I call it single payer. It's about access. It's about affordability. It's about time, Democrats."
Newsom finished first in the party endorsement vote with support from 39 percent of delegates. Villaraigosa finished last with 9 percent.
But Villaraigosa is not alone in his criticism of single payer as currently envisioned. After SB 562 passed the state Senate last year, Assembly Speaker Anthony Rendon said he would not let it reach the floor of his house without more meat on the bones.
That announcement put the nurses union on the warpath, even threatening to launch a recall campaign against Rendon. Since then, the Assembly has held informational hearings on SB 562, but there's been little progress toward moving it forward.
"It was a bill that was woefully incomplete," Rendon said on KQED Forum in December. "Imagine a bill that comes at a price tag of $400 billion but doesn't identify a funding source."
Gov. Jerry Brown has also expressed skepticism about single-payer health care. Referring to the estimated $350 billion to $400 billion price tag, Brown asked "Where do you get the extra money?
This is the whole question."
In response, the nurses union points to a 2017 study by the University of Massachusetts Amherst. It found that a single-payer system would increase costs to California (government, employer and individuals) by just under 10 percent. But it also found a significant potential for cost savings from administration and prescription drugs and reduced inefficiency, with the net effect being an overall savings under single payer.
Still, implementing single-payer health care in California would require buy-in from the federal government, employers and the insurance industry, says health policy analyst Marian Mulkey.
"[Single payer] is a complete upending of the way that health care is paid for, and financing is a very far cry in terms of conception from Healthy San Francisco," she said. "And that would be a huge transition to negotiate and to manage."
And so, while single-payer health care might be politically popular right now, huge hurdles remain. And whether Gavin Newsom could do anything to overcome that as governor is very much open to question.