Covered

This story is part of a series that explores the relationship between California and Donald Trump’s Washington.

After Donald Trump won the presidential election, California state senator Ricardo Lara started to sound a little delusional. Lara, a Democrat from Los Angeles County, had made a name for himself writing legislation to let undocumented Californians access health care through the Affordable Care Act. As of 2016, 93 percent of Californians were insured — far more than ever before — and Lara’s legislation was expected to send that percentage higher. Then came Trump and his promises to dismantle Obamacare. People tried to sympathize with the senator. All that hard work for nothing. Lara just looked at them and said, with a mystifying air of certitude, that he still planned to get everyone in California insured.

Three months later, Lara explained himself. With Senator Toni Atkins, a Democrat from San Diego, he introduced a bill to enact universal, state-funded health care through a single-payer system. It would replace private insurance, Medicare, and Medicaid and would cover every Californian, even the undocumented. The state would directly pay doctors, hospitals, and drug companies, and people could see whomever they wanted, including specialists, and take whatever medicine they needed, with no copays or deductibles. The system could be funded both through taxes and by diverting federal Medicare and Medicaid funds. Lara hadn’t exactly come up with the single-payer bill himself — the California Nurses Association had brought the idea to him — but he positioned himself as its champion. “Given the uncertainty of what’s happening at the federal level and President Trump hell-bent on the demise of the Affordable Care Act,” he told kpcc, the Southern California public-radio station, “it’s up to California to come up with a better plan.”

Lara’s parents immigrated illegally to the U.S. from Mexico before he was born. When he got the flu, they’d leave him with the school nurse instead of letting him stay home. Years later, he realized that their family hadn’t had health insurance, so the school nurse was their best bet at getting care. Lara hated that Obamacare hadn’t been written, at the outset, to include undocumented immigrants; health care, as he saw it, should be a human right. And in a perverse way, Trump’s antagonism toward Obamacare presented him with an opportunity.

“I was thinking, OK, let’s not let this crisis go to waste,” he told me not long ago, sitting in his office in the capitol building. Lara, who is 42, is a political veteran; he was a state assemblyman before becoming a senator, and he now chairs the Senate Appropriations Committee. He plans to run for state insurance commissioner in 2018. (One health care advocate who supports the single-payer bill suggested to me that Lara’s enthusiasm might also be an effort to raise his political profile ahead of the election.) Lara’s effort to give undocumented immigrants access to not only Obamacare but college loans and professional licenses has earned him a reputation as a particularly effective member of the legislature’s progressive wing. He speaks, though, with the defiance of a political outsider. “We as California have to send a message to D.C.: If you continue to screw with our health care, we’re going to move to single-payer,” he told me. Behind him, on a windowsill, stood a Trump piñata that a friend had given him. At the end of the year, he planned to smash it open.

There was something tantalizing about the idea of California responding to Trump’s threat to dismantle Obamacare by beating him to it — the sort of trolling that Trump himself might admire. Senator Scott Wiener, a Democrat from San Francisco who supports the bill and is a friend of Lara’s, told me, “There are issues, whether it’s immigration or climate change or health care, where we’ve always had certain values in California. Trump threatening those values so deeply gives us an incentive to protect them and a sense of urgency.”

States have pursued single-payer systems for decades, but none has made it into law: In 2006 and 2008, the California legislature passed bills, but then-governor Arnold Schwarzenegger vetoed them; Vermont pursued a single-payer system in 2011 but later decided it’d be too expensive. And just last year, Colorado voters rejected a ballot measure that would have given them universal health care. Economists generally agree that single-payer systems cost less, partly because governments can limit the prices paid to doctors and drug companies. Some experts argue that these systems bring about better health outcomes, too, though this is a subject of debate. Still, a state can’t just force companies and people to funnel their would-be insurance payments to the government. It has to tax them, and that’s rarely popular.

A statewide single-payer system presents logistical challenges as well. State governments have to balance their budgets, which could lead to big health care shortfalls during weak years. Single-payer could also lead to longer wait times. And a state would have to apply for federal waivers to divert Medicare and Medicaid funds into its system. If Lara’s bill became law, he’d be in the awkward position of having to ask Donald Trump to help make it happen.

In April, Lara returned from a fact-finding mission to Canada, where he’d met with government officials and health care providers to get ideas for crafting California’s plan. He told me, “People were like, ‘We know there’s been efforts in Vermont, in Colorado, but California — this is huge.’” Back home, the response was more equivocal. Bernie Sanders was planning to introduce a federal single-payer bill, and a national poll had shown that more people supported a federal single-payer plan than those who opposed it. But in California, the critics were getting more vocal. In March, Governor Jerry Brown suggested a single-payer system could be too expensive to implement. California’s budget is about $120 billion total in a good year — more, by far, than any other state. Single-payer is expected to increase costs substantially; the governor pegged the total at $300 billion for health care alone. Brown argued that proponents of single-payer were trying to solve a problem by creating an even bigger one. “It’s not,” he told reporters, “a pathway that can be followed.” (A spokesman said the governor had no further comment.)

With the bill’s first hearing planned for the next day, Lara acknowledged that “it could be a long fight.” After this hearing, there’d be one in the Appropriations Committee, then a vote in the Senate. Then it’d happen all over again in the Assembly. The process could take more than a year, and even if the bill passed, Brown could veto it.

The following afternoon, hundreds of nurses crowded into the Senate Health Committee’s hearing room, taking selfies and gently heckling the corporate lobbyists in attendance. Lara watched as a parade of bill supporters lined up at a microphone, followed by a shorter line of opponents. Then came the senators’ questions: How would you pay for all this? (TBD.) What if the Trump administration didn’t let California use federal funds for the system? (The state could sue.) In the end, the committee’s members voted overwhelmingly to let the bill progress.

Afterward, the public policy director for the California Nurses Association, Michael Lighty, approached Lara and asked, “Are you happy?” I later asked Lara how he’d responded. He was glad it was over, he said, and smiled. Of course, he knew it wasn’t — he’d just gotten through one hearing. The following week, the U.S. House of Representatives would pass a bill to replace Obamacare with a program that would restrict health insurance access, particularly to the low-income people Lara was most concerned about. On the windowsill not far from his desk, the Trump piñata stood intact.