California’s health care system has made great strides under the Affordable Care Act. Among many signs of progress, the state’s uninsured rate has been cut in half to 8.5%. Universal health care coverage in California is finally within reach, a goal that seemed like a long shot only five years ago.
Through the California State Assembly’s Select Committee on Health Care Delivery Systems and Universal Coverage, and other forums, California is exploring a variety of policy options to get the state across the finish line to universal coverage. Over the past year, mirroring growing national interest, there has been momentum in California to create a state-based, single-payer system.
Despite that interest, there is no broad, shared understanding of what the term single payer means. The California health care system affects tens of millions of lives, provides hundreds of thousands of jobs, and costs hundreds of billions of dollars each year. Any major proposed reforms to that system warrant a rigorous analysis and a shared understanding of the goals and implications of reform.
The California Health Care Foundation (CHCF) commissioned a new report, Key Questions When Considering a State-Based, Single-Payer System in California, to provide a basic understanding of the core features of a state-based, single-payer system and to explore the major issues at play in the creation of such a system. The report does not take a position on single payer, nor does it analyze specific single-payer legislation or proposals. Instead, it provides a baseline understanding of what a single-payer system is, what it isn’t, and what its implementation might mean for California.
Goals Drive Policy
Like any policy, the feasibility and effectiveness of a state-based, single-payer system in California ultimately depends on its main goals. Different goals trigger different trade-offs and a variety of nuanced implementation choices. The paper identifies some of these possible trade-offs and raises pivotal qu
estions about any single-payer proposal for California. Some are questions that should be asked about any major health care reform policy; others are more specific to single payer.
The paper also discusses other crucial questions, such as: What money is available to support a single-payer system in California? Who would be eligible to use it? What benefits and services would be covered? How would payments to health care providers be set and structured? How would a single-payer system be governed and held accountable? The paper provides a framework for considering these questions and the implications of different choices.
Our goal was to produce a resource valuable across the political spectrum. It is one of many ways CHCF seeks to inform the dialogue around how California can move toward universal coverage. In the coming months, we also plan to provide analysis and resources around other policy options that could potentially help the state achieve universal coverage.
We encourage readers to ask the important questions in this paper and consider the opportunities and challenges they present. This will allow us to gain clarity about our main goals for further health care reforms — and what it will take to achieve them. No matter what path California ultimately takes to achieve universal coverage, asking the right questions now can only improve the prospects for success.
Sandra R. Hernández, MD, is president and CEO of the California Health Care Foundation. Prior to joining CHCF, Sandra was CEO of The San Francisco Foundation, which she led for 16 years. She previously served as director of public health for the City and County of San Francisco. She also cochaired San Francisco’s Universal Healthcare Council, which designed Healthy San Francisco. It was the first time a local government in the US attempted to provide health care for all of its constituents.
In February 2018, Sandra was appointed by Governor Jerry Brown to the Covered California board of directors. She also serves on the Betty Irene Moore School of Nursing Advisory Council at UC Davis and on the UC Regents Health Services Committee. Sandra is an assistant clinical professor at the UCSF School of Medicine. She practiced at San Francisco General Hospital in the HIV/AIDS Clinic from 1984 to 2016.
Sandra is a graduate of Yale University, the Tufts School of Medicine, and the certificate program for senior executives in state and local government at Harvard University’s John F. Kennedy School of Government.