Michael Lighty has organized, advocated, and developed healthcare policy nationally and in California for nearly 30 years. He is a founding Fellow of the Sanders Institute. He was lead policy analyst, a leader of Healthy California and testified on behalf of the single-payer bill, SB 562. He has toured the US as a spokesperson for Democratic Socialists of America’s Medicare for All campaign. He served as Healthcare Constituency Director for Bernie 2020. We are honored to feature his exclusive report for our coalition, Healthy California Now.

California Single-Payer: Report and Strategic Recommendations

The single-payer healthcare movement in California and nationally is at a crossroads.

The political context for healthcare reform has been set by the defeat of the Bernie Sanders campaign, the coalescence around a public option, and the strong opposition of the Joe Biden campaign to Medicare for All. Few elected officials, at the state or federal level, are talking about single-payer, and there is no new interest among mainstream health reform advocacy organizations for deeper engagement in the single-payer movement.

However, we are also seeing high levels of popular support for single-payer, a pandemic that demands a robust public health response, and health inequities devastating Black, Native, and Latinx communities. With the political landscape dominated by the COVID-19 pandemic and the Black Lives Matter uprising, along with the economic fallout from them, there is new interest among single-payer activists to link the exposure of health inequities to the demand for guaranteed healthcare through an improved Medicare for All system.

Our primary challenge is how to build a movement capable of translating these conditions into a winning political demand.

Ultimately, we cannot win single-payer as a stand-alone demand; it must be the health justice plank in the rising Third Reconstruction movement that challenges systemic racism. As such, it could be a leading-edge, unifying demand that addresses systemic inequalities while providing substantial healthcare and economic benefits to all low- and middle-income workers.

This report summarizes conversations, meetings, and presentations on the current moment in U.S. and California politics relating to healthcare policy and racial justice.

The results are seven recommendations that make up a strategic approach that creates a different context for our organizing, changes the terms of debate, moves from the compelling policy case to new levels of movement building, and takes the fight to the industry that is denying us the care we need.

UPDATE: This report, including the following recommendations, was presented to Healthy California Now members on September 10, 2020. On September 15, 2020, the Healthy California for All Commission announced a hiatus throughout the rest of 2020. We are presenting the report and recommendations as is, because the findings and necessity still stand, now more than ever.

Strategic Recommendations

Part of our task is to challenge the ideology of “possessive individualism” that isolates us and fuels the anti-social tendencies, particularly among white people, that are expressed in anti-mask activism and resistance to social distancing, and other collaborative approaches to limit the spread of COVID-19. We need to be explicit in demanding a socially conscious “caring economy” rooted in solidarity, kindness, and mutual aid, and committed to achieve a more equal and just society as the only solution to the pandemic and to the economic crisis it has created, including the crisis of health inequities and insecurity. This perspective must frame and inform our rhetoric, our strategy, and our tactics.

I suggest the following strategic actions to move our work in California forward based upon a two-pronged approach of moving inside players — the Governor, state and federal elected officials, and Healthy California for All Commission members — and building our organizational capacity and resources.

Build real, ongoing relationships with racial justice organizations. This requires us to foreground state-sanctioned violence, police brutality, and mass incarceration in the fight for guaranteed healthcare, so that when we say Medicare For All it is understood to mean, as a top priority, that Black Lives Matter. Specific work would include:
- Promoting and participating in ongoing Zoom presentations by Healthy California Now (HCN) and its affiliates, and other webinar series, such as “Racial Justice and single-payer” beginning later this month through December, which will include a session on white allyship;
- Supporting the “Care Not Cops” agenda of local efforts to shift resources from police to social services and healthcare — particularly high-profile fights such as those around the LA People’s Budget and reform of the Alameda Health System;
- Engaging deeply with the Schools and Communities First – Prop 15 campaign to win that reform and build relationships with the social and economic justice organizations that are part of the campaign.
Organize healthcare workers to demand single-payer, including speaking out about the reality of healthcare in the time of COVID-19 and pressuring healthcare employers to support single-payer through on the job, corporate accountability, and other actions.
Push a mass petition to Governor Newsom demanding that he develop the federal waiver he pledged to pursue upon taking office, saying it was necessary to authorize California to consolidate and make available federal resources for a single-payer system. The waiver would be submitted in the first month of the Biden Administration. Its submission and approval would change the conversation from “whether” to “how” we do single-payer. The momentum created would dovetail with a campaign to get the legacy healthcare foundations to fund policy development and build popular support for a legislative effort and possible initiative campaign to enact and finance single-payer.
Build a grassroots campaign in every corner of California that demands guaranteed healthcare, targeting legislators as they seek re-election in November to support single-payer legislation next session. Tactics would include phone banking, district meetings, constituent organizing, and direct action if possible, in as many legislative districts as feasible. Wolf PAC and 99 Rising efforts to move clean money legislation can serve as a model – with super volunteer organizers deployed in districts throughout the state, and direct actions carried out in Sacramento.
Establish a sub-committee within Healthy California Now to coordinate public testimony and ex parte engagement with the Commission and its individual members, which would include coordinating strategy with sympathetic Commissioners, making lobby visits and posing targeted questions to skeptical/opposing Commissioners, generating credible challenges to the framing, background, and findings generated by the Commission’s consultants, and carrying out a communications plan to publicize our views and public comments.
Drive demands in support of national legislation. Legislation, such as HR 5010 and especially the Healthcare Emergency Guarantee Act, must be part of this mobilization, and we should push to get as many California Congressional co-sponsors as possible on those bills.
Establish individual memberships in Healthy California Now, based on a modest fee (on the order of $5) that would fund grassroots activity and expand our activist base. Organizations could pay on behalf of their members and individuals could join directly.

Context

Outside of the spotty availability of free or subsidized COVID-19 testing in certain places, virtually nothing has been done to address people’s loss of healthcare coverage and need for expanded coverage during the pandemic. This includes both the failure to address the uncovered costs of physical health services for COVID-19 and the failure to expand mental health services to address the impacts of the pandemic on already high levels of unmet need, particularly among Black and immigrant communities subject to toxic levels of stress and violent policing as conditions of everyday life. Despite so much of U.S. politics being driven by partisan identification, Democrats and Republicans both have failed to expand healthcare coverage or alleviate the costs of testing and treatment for SARS-CoV-2 in a consistent way.

The $4.5 trillion bailout of large corporations and wealthy investors, driving a tech-led stock market surge further enriching billionaires, contrasts to the $350 billion provided to hospitals and health facilities to meet the shortfalls and demand created by the pandemic. Some of these hospitals are hugely profitable, including Tenet, which reported over $1 billion in second quarter profits. Meanwhile, the country’s largest health insurance companies reap record profits, with United Health Group reporting over $6 billion in Q2 and Kaiser Health Plan reaping $4.5 billion.

In California, the pandemic period has also seen the reemergence of the Healthy California for All Commission. It has a mandate to establish a plan for “unified financing” of healthcare in California. But the consultant team has been relentless in forcing consideration of the barriers to single-payer and wants to focus on delivery, workforce, and reimbursement reforms, while downplaying single-payer’s capacity to generate savings and improve patients’ access to care.

These elements — a surging pandemic, the lack of a coherent health policy response, and the intensification of debate over police violence in Black and immigrant communities and the expansive role of policing in U.S. society more broadly — have defined the focus of this report. Originally intended to assess the potential opportunities to build alliances to establish a single-payer, universal healthcare system in California, this interim report instead now examines the uprising, the demands facing healthcare non-governmental organizations, the grassroots pressure for single-payer, the role of the Healthy California for All Commission, new alliance building with racial justice organizations, the intensifying crisis facing labor unions, and the potential for November ballot fights to shape prospects for single-payer next year, and arrives at strategic recommendations that reflect the comprehensive context for single-payer advocacy, nationally and in California.

Challenges and Opportunities

There is no new interest among mainstream health reform advocacy organizations for a deeper engagement in the movement to win single-payer in California or nationally. However the Healthy California for All Commission has led to public statements of support for single-payer, and engagement in that Commission as a vehicle to establish universal healthcare, by representatives of these organizations. Most notable are the statements of Anthony Wright, Executive Director of Health Access, who expresses his support for “single-payer” at public meetings, and some foundation representatives who are now articulating the need for “unified financing.” As a leading consumer advocate said, however, no elected official is “talking about single-payer. Nor is anyone else. It is not on anyone’s radar.”
There is little support for single-payer among elected officials at the state or federal levels. The political context for healthcare reform has been set by the defeat of the Sanders campaign, the coalescence around a public option (even among congressional advocates of Medicare for All), and the strong opposition of the Biden campaign to Medicare for All. Sen. Kamala Harris was famously for Medicare for All before she was against it, so some advocates see an opening with her nomination for V.P. The leadership in the U.S. House and their leadership counterparts in California currently have no interest in pushing for single-payer.The wholesale rejection of Medicare for All in the DNC platform is the clearest expression of that, reflected in the non-Medicare For All recommendations of the healthcare Democratic Unity Task Force, and in Democratic nominee Joe Biden’s recent definitive statement, “it will not get on my desk.” The platform votes against Medicare for All by California Secretary of State Alex Padilla and Superintendent of Public Instruction Tony Thurmond reveal the disregard for the CA Democratic Party’s official support of single-payer, and the 88% support among national Democrats for Medicare for All.
COVID-19 represents an ongoing existential threat to health and social service organizations in communities of color. These organizations are struggling to provide food assistance, healthcare, and mutual aid as needed to their constituents; there is an on-going need for funding of current and expanded services, and a focus on preventing evictions and mitigating risks of exposure to the virus. As one advocate reported, “we are just trying to keep our community partners afloat, and people fed and housed.” Unemployment and unsafe essential workplaces, with high rates of transmission, lack of workplace testing, dense living quarters, inadequate home schooling, and heightened mental health issues characterize daily life for California’s many low-income, predominately Black, Latino, API and Native neighborhoods.These are not new issues, but rather long-standing dynamics of racial, social, and economic stratification starkly revealed and placed in relief by the pandemic.

This wasn’t news to Black, indigenous, and Hispanic Americans, who are subject to mass incarceration, have significantly lower incomes and higher unemployment rates that the white population, and for whom the healthcare system and the overwhelmingly segregated education system and housing market have never provided equitable care, opportunity or provision. As a result of these inequities, they are being infected and killed at a disproportionate rate. (Hazel V. Carby, LRB 30 July 2020)
Racial and economic justice organizations support single-payer but it is not their immediate focus. In California, Reform LA Jails, Black Youth Organizing Project, ACCE, and other groups organizing to pass Prop 15 for Schools and Communities First, are among the racial and economic justice organizations that support Medicare for All. Health Access and its affiliates support single-payer, but work on other immediate reforms. A new coalition named Commit to Equity has formed, which includes Health Access, health advocacy organizations such as CPEHN, and large unions such as SEIU, and which is advocating for a statewide wealth tax to fund expanded social justice programs.The Poor People’s Campaign, Movement for Black Lives, NAACP, Rising Majority, and Mijente are national organizations devoted to end state-sanctioned violence and mass incarceration, and promote racial justice and freedom for Black and brown people, which also support Medicare for All as part of their overall reform programs.
Police reform and inmate release programs are influencing local elections. Fights to defund the police and expand inmate release programs are dominating local government budget discussions throughout the U.S. and in California (particularly in Minneapolis, New York City, Atlanta, Chicago, Detroit, Portland, Seattle, Oakland, San Francisco, and Los Angeles), and are shaping upcoming elections for city councils and district attorney. Significantly, no national or state legislation, and only relatively modest reductions in police budgets, if any, have been enacted so far, though criminal justice reform bills are moving in state legislatures.
Single-payer groups and NGOs are ready to push for a bill in California. Despite or because of this crisis and the lack of more mainstream interest in single-payer, NGOs such as the Inland Equity Partnership (a coalition of community-based organizations in the Inland Empire) and single-payer groups including Healthcare for All – Los Angeles, PNHP, Our Revolution-California, Democratic Socialists of America, Progressive Democrats of America/California, and Black Lives Matter-LA, have undertaken heightened agitation against the Healthy California for All Commission, demanding action by the Governor, and pushing for single-payer legislation. One of these activists put it succinctly: “We need to go all out between now and November to get elected legislators to commit to doing a single-payer bill next year.”
State ballot proposition fights open the door to new alliances. Ballot fights in California over increasing taxes on commercial properties (Prop 15), affirmative action (Prop 16), rolling back parole eligibility (Prop 20), rent control (Prop 21), and treatment of ride share workers (Prop 22) loom as flash points on race and economic justice. These organizational efforts, especially the large-scale campaign for the Schools and Communities First measure (Prop 15), “point to a potentially powerful new alliance post-November for health equity and for single-payer,” as a longtime Medicare For All-friendly executive director of a statewide advocacy organization put it.
Insurance industry-backed California foundations do not support single-payer. Not surprisingly, California-based foundations funded by insurance company conversions to non-profit status with the mission to expand access to healthcare for Californians have not devoted any substantial resources to policy work in support of single-payer, Medicare for All reform. In a recent opinion piece, the CEO of the largest of these foundations, The California Endowment, referenced single-payer simply as “not enough,” without providing any specifics on what would be necessary to make it “enough.” In more than two decades of existence, this foundation has devoted at least $100 million to promoting and implementing the Affordable Care Act, and at least $1 billion to the Healthy Communities initiative, whose target communities have been devastated by COVID-19, while producing only one white paper on policy questions related to single-payer. That CEO and the CEO of the California Health Care Foundation, who is arguably even more strongly opposed to single-payer, are both members of the Healthy California for All Commission.
Healthy California Now continues to be the leading state coalition in support of a single-payer, Medicare for All system. Underwritten by considerable resources from NUHW, the coalition comprises mostly organizations with strong histories of single-payer advocacy in California, with the California Alliance of Retired Americans playing a key role along with Healthcare For All – California, PNHP, Business Alliance for Single-Payer, and others. Many of these organizations want action now from the Governor and the Legislature, and are skeptical that the Commission can overcome the biases of the consultants. “We don’t expect much,” is a familiar refrain. Racial justice organizations are not represented strongly in the coalition, and labor participation has fallen off from its 2018 high point. A labor leader active in 2017–18, said that after the November 2020 election will be the time to “push labor to engage again in the fight for single-payer, and we can win this.”