How California’s single payer debate will drive national Democratic politics

I sort of hate to tell you this, but the first Democratic Party sanctioned televised debate among candidates for the nomination for President is coming up in June, now just five months away.

The Democratic field of candidates for the nomination is going to be a big one.  It’ll be a broad mix of folks trying to stand out in a crowd, hoping to make it at least to the first Iowa caucus in February.  Early candidate lists include as many 34 candidates thinking they might become the next Commander in Chief.

So, whether we like it or not, it’s time to start thinking about what might be in store for our national politics.

And, given a range of reasons I outline below, I think the conversation about moving California to a single payer model of health care could have significant national implications for Democrats.

Here’s why.


1.  Standing out in a crowded field requires extreme positions. 

What we know from crowded nomination contests we learned, in part, from the Republican nominating contest in 2016.  Rather than 34 candidates, the Republicans only had a paltry 17.  Among those candidates who started the race, some ended with millions of votes (Trump, Cruz, Kasich).

Many ended with just a handful.  Bobby Jindal earned 200 votes before he dropped out. George Pataki had 2,000.  You get the idea…

The reality is that in a crowded field, the lights, camera and attention will go to the candidate that is willing to take the more extreme positions.

And, while the “extreme” might not be a majority opinion at first, holding a strong 15-20% of a vote – even 10% of the vote – in a crowded field could be more than enough to win a primary.

With as many as 30 candidates likely running as traditional progressives, there will be a handful of folks willing to run to the far left in order to get attention.

So, let’s apply that to health care policy.


2.  Is a single payer proposal a far left proposal? Not for Democrats. For Democrats, its sine quo non.

The answer is “It depends – on a couple of things.”

First, it depends on what you mean by a single payer proposal.  The idea of a single payer model means a lot of different things to a lot of different people on the Democratic left.  And, there is no unifying effort to clean that up.

For some, it means universal coverage. For others, it means government administered and financed care. For others it means Medicare (or Medicaid) for all, which would include the private Medicare Advantage plans.

Voters that support a “single payer” platform don’t get caught up in the details of implementation, however.  So, candidates may not need to either.

We know this:  if you want to win a Democratic primary, you can’t be against a single payer model of health care.  Just ask Anthony Villaraigosa.  His campaign against Gavin Newsom turned on this issue, staking out a more moderate ground than Newsom’s support for single payer.

It didn’t work.

This brings us to another variable in how one can answer this question: it depends on who is answering.

If you ask Democrats, an overwhelming amount of Democrats – 84.5% according to a recent poll by Reuters – say they support a Medicare for All proposal.  That’s even more than support for “Free college tuition.”

It turns out even a majority of Republicans support such a proposal.

So, it would seem that support for a single payer model of health care is not only a mainstream policy, but increasingly it would appear that opposition to such a model would be considered “extreme” among base Democratic voters that show up at caucuses and in primaries.

In other words, you can’t not be for a single payer policy in a crowded field – unless you decide to try to win the Democratic nomination from the “extreme” right.  I’m not sure that’s been a winning strategy for Democratic candidates – unless you want a job in a Republican administration rather than a Democratic one.  Ask Jim Webb.


3.  So, how does California get involved?  It holds a primary March 3rd, 2020.

The first caucus in the nation is the Iowa caucus on February 3rd.  There it will award 50 delegates in a proportional allocation based on performance.  New Hampshire will hold the first Primary in the nation on or before February 11th.  It will allocate 33 delegates.

However, California has moved up its primary to March 3rd.  Because of new rules for delegate allocation that includes an increase delegate award based on the total number of Democratic votes in the state, as well as overall population, the state of California will be awarded 492 delegates.  More delegates will come out of LA County than will come out of 40 other states.

With early voting in California, I’m told by one political consultant that there will be more votes cast in California’s early voting that are completed ahead of Iowa’s Feb. 3rd caucus than will be cast by all Iowans in the Iowa caucus.

So, while there will be hype about IA and NH, don’t buy it.  California will be the most important early state on the calendar.

And, because of a new model of proportional awards of delegates to candidates, winning 5% of the California vote could mean winning almost 25 delegates alone – almost as many as all of the New Hampshire delegates.

But, in a crowded field, it will be almost impossible to win delegates without a single payer model of health care to promote.


4.  And why this legislative session? Because of all of the above and below.

There are only a few states in the nation with leaders that have seriously toyed with the idea of a single payer system. California’s legislature is one of them.  California’s governor is another.  And, together, that support has given single payer advocates a great deal of hope for the 2019 session.

Moreover, Newsom’s early appointments to his administration have created some excitement among stakeholders that he is primed to do something big in his term.  From Anthony Wright, Executive Director of Health Access California:

“These are the appointments of a governor who is serious about doing something big on health care.  You have folks who have engaged the issue very seriously and have the scars to prove it.”

So, this is a legislative year primed for action on single payer.

If a bill moves to Newsom’s desk, it’s likely that California’s approach will inform a wide array of Democratic hopefuls as they develop their own platforms.

And, if a bill stalls, there will likely be a lot of advocates fired up, and ready to go to work to get a candidate votes in California that can deliver on a single payer model of care where the state otherwise stalled.

In other words, this session is going to materially impact health policy and politics in the national Democratic race for the nomination if a single payer bill moves – and also if it doesn’t.


Bottom line:  Expect the Democratic contest for the nomination for President of the United States to get here before we know it.  Expect that supporting a single payer policy for health care is a requirement to get the nomination.  And, expect that what happens in the California legislative session will provide important context and momentum for what happens at the ballot box in California on March 3, 2019.