For the third time, CalCare, a proposed state-run universal healthcare system, has failed to advance, once again stalling amid familiar political arguments and cited financial barriers. 

Officially known as Assembly Bill (AB) 1900, the California Guaranteed Health Care for All Act would have provided comprehensive medical, dental, and vision services to all residents, regardless of immigration or employment status, while also eliminating private insurance requirements, premiums, and deductibles as a single-payer system.

“It’s a real tragedy when people are sick and suffering, that they, in this country, also have the added stress of, ‘How am I going to pay for this bill?’ Most GoFundMe accounts are for Americans to pay their healthcare bill, and these are people with insurance,” said Erika Feresten, co-founder and chair of Health Care for US (HC4US), a nonprofit all-volunteer organization dedicated to getting free public healthcare.

HC4US is one of more than 300 organizations that endorsed this act. Among this group, one of its most vocal supporters was the California Nurses Association (CNA), which has consistently backed State Assembly member Ash Kalra, one of the bill’s primary authors, in the cause. Following the California Assembly’s recent decision not to advance the legislation, the CNA “condemned” it, saying they’d rejected what should be a human right. 

“The nurses are the ones who have written this bill. They’ve done the traveling, the research, and the financial studies. While we love our doctors, the nurses are really on the front lines of our health insurance system, and they are seeing people being denied life-saving surgeries because insurance doesn’t approve them, medicines, treatments, and so forth,” Feresten said.

The organization has sponsored versions of this single-payer healthcare bill for decades, with its efforts going as far back as 1994. 

“Every industrialized country in the world has a form of free public healthcare. Their systems recognize every human being as having a right to healthcare. But in the United States, our system is for-profit. People here don’t have it as a right. It’s if you can afford it, you get it, and if you can’t, you just don’t get it,” Feresten said. “I don’t understand why, in the wealthiest country in the world, and California is now the world’s third-largest economy, we don’t put money and resources into having everyone in a high-quality healthcare system.”

Feresten argues that not only is the money already there, but so is the support. According to a poll by the CNA, over 40% of participants said healthcare has become harder to afford in recent years.

“Of most unhoused people, about 40% have full-time jobs, but are so underwater in debt that they can’t make enough to get housing. And that debt is almost always a healthcare bill,” Feresten said. 

But the issue has been expanding over the past decade. California residents are currently seeing an unemployment rate higher than the national average, hitting more dramatic lows than the rest of the country during economic downturns. The majority of key industries have shed jobs over the past few years, causing many to lose employer-provided insurance coverage, according to the California Employment Development Department.

All of these cutbacks have led the California Legislative Analyst’s Office to predict that, by 2030, the two million residents without health insurance right now will double.

“A lot of people will use the argument that we have an emergency room that anybody can show up for, and, yes, an emergency room works if you have an accident or to treat immediate needs, but an emergency room is not going to give you your ongoing cancer treatment, and many people in the United States make the decision to die instead of getting the treatment because they don’t want their spouses or their children to be financially ruined,” Feresten said.

As frustrations over healthcare costs grow, so has support for a universal healthcare system like CalCare. According to a CNA study, three-quarters of respondents said they would vote for a governor who backed such a system, a sentiment that has begun surfacing in several Democratic candidates’ campaigns over the past month. In some cases, politicians who previously opposed the idea have since shifted to support it. 

Yet despite their decades of campaign promises and public support, progress has been elusive. Many of these supporters are now questioning whether there’s any truth behind their words.

“Our politicians get a lot of money from insurance companies, from big pharmaceutical companies, from hospital associations, and from medical device companies, and they don’t want to lose those campaign donations and that support. So, obviously, they’re not going to campaign well if they come out and say that’s why they’re not going to pass this because they’re supposed to be representing the people,” Feresten said.

Gov. Gavin Newsom himself, who pledged to pass it when he ran in 2017, is an example of this, heavily criticized for appearing to back away from it shortly after taking office. As he holds a Democratic supermajority in the state legislature and leads the party as a Democratic governor, Feresten believes the bill’s repeated failures are not accidents.

“The California nurses endorsed him because they believed him. But, as a mom, I tell my children, ‘Don’t pay attention to what people say, pay attention to what they do.’ This is the third time the nurses have brought this bill to Newsom in his time as governor. He’s had three opportunities to make good on this promise, which we all believed,” Feresten said. “But we believe, in the room where the real negotiating takes place, he’s giving an order to his party to make sure this doesn’t get on his desk so that he doesn’t have to vote. If it had gotten to his desk, he would have had to sign it; otherwise, it would have been his political downfall.”

This ability for political leaders to assume plausible deniability highlights the larger issue in the healthcare system right now: unequal access and unequal accountability. According to Feresten, single-payer systems are designed to eliminate inequalities such as these.

“One of the main principles is that everybody is in and nobody is out. In other words, the governor and our unhoused neighbor would be in the same system, treated with the same high quality, because both lives are highly valued,” Feresten said. “Separate is never equal because what always happens is that those who are in power defund. They take money out of the other system and put it in their own system. The only way to prevent that is if the people in power were in the same system, so then they and their children would also be suffering.”

While the proposal has gained significant traction, it continues to face much resistance in government, the majority of which involves raised financial concerns.

Implementing it would require federal approval to redirect funding from programs like Medicare, Medicaid, and veterans’ health coverage, a request many believe would be unlikely to be approved under the current administration. 

Dr. Anthony DiGiorgio is a neurosurgeon at the University of California, San Francisco and at Zuckerberg San Francisco General Hospital and Trauma Center, where he is involved in Medicaid policy and healthcare access research. He is also affiliated with the Philip R. Lee Institute for Health Policy Studies.

“Right now, if you have a job and you pay taxes, part of those taxes go to the federal government to fund Medicare,” DiGiorgio said. “So for CalCare, you’d have to ask the government for a waiver to keep the funding within California. Operationally, it would require cooperation with the federal government, which I doubt California would get right now, and even if they were to get it from a future administration, if another administration was unfriendly to California, they could always undo it.”

Its price tag has also become a central debate. Its most recent rejection argued that not only would CalCare cost more than the entire state budget — $731.4 billion a year, which is more than three times it — but California is facing its fourth consecutive year of budget deficits, alongside continuing cuts to healthcare funding following President Donald Trump’s signing of the One Big Beautiful Bill Act, which cut $1 trillion in the sector, the largest coverage loss in U.S. history. 

“Those are disingenuous concerns. That’s health insurance, big pharma, and hospital association propaganda,” Feresten said. “If California is basically the world’s third-largest economy, following China and Germany, and the United States is the world’s leading economy, it doesn’t make sense. You have Italy, France, Germany, Switzerland, Japan, Norway, Sweden, and on and on, with much smaller economies, that have this system for their people. If they can afford it, we certainly can afford it.”

Still, any remaining funding gap would have to be made up through taxes, taking from businesses and individuals alike. Vermont faced the same issue in 2014; however, the required taxes couldn’t be sustained, and its single-payer system had to be removed.

“I don’t see it ever being feasible. Vermont was not able to make it work. If a teeny little homogeneous Vermont couldn’t make it work, I think the chances that something feasible would ever be able to make it in California are close to zero,” DiGiorgio said.

Dr. Dianne Storey is an internal medicine physician at Sutter Health. She considers how her patients might react to these taxes as residents currently on private insurance plans.

“There’s a lot of wealth in California, so you’re going to have a lot of people who aren’t going to want to be taxed at a rate that’s going to allow for this to be funded,” Storey said. “I also practice medicine in an area of California that’s wealthy. Pretty much everybody in my practice is insured by either Medicare or a commercial insurance company, so I would venture to say that most people who are covered by a private insurance company would not want to see this pass in the state.”

DiGiorgio also sees the concern about replacing existing insurance coverage with one state-run plan for all.

“I think, ultimately, it would be unpopular because people tend to like their private insurance,” DiGiorgio said. “Imagine everyone in California who has Kaiser Permanente would no longer be able to have their Kaiser insurance if CalCare went through because the basis of single-payer is that you can’t have private insurance. You have to have the state-provided one.”

“Our doctors are suffering what’s called moral injury. This is where doctors in the United States are not free to practice medicine because when they feel that their patient needs a test, a certain medication, an operation, or treatment, the insurance companies are denying it,” Feresten said. “I was talking with a pulmonologist who worked closely with us, and he talked about how demoralizing it was to be a doctor, and to have spent all this time in education, and then basically have to beg insurance companies to approve, while they question him when they’ve never even met with the patient and don’t even know what’s going on.”

Feresten uses this to explain why healthcare cannot be private, as it currently is: profit becomes prioritized over medical need.

“Right now, if they will make a profit by denying you an X-ray you need, they will deny you an X-ray. If they will make a profit by giving you X-rays that you don’t need, then you end up getting X-rays you don’t need, which is not good for your health because there’s radiation,” Feresten said. “CalCare means it’s just you and your doctor asking what it is, and giving you exactly what you need — not less, and not necessarily more. It brings the authority back to the healthcare provider.”

Additionally, in a single-payer system, there would be more flexibility in provider selection, since residents would no longer be restricted by the coverage of their employer’s chosen insurance.

“If they didn’t like a doctor’s opinion, they could easily get a second or a third opinion to help make a decision, whereas now, a lot of times, you’re stuck with the doctor that your insurance dictates that you have,” Feresten said. “We don’t even have the freedom to choose, really, our own doctors, because people receive insurance through their jobs, and those jobs pick whichever plan, and that plan decides whichever doctors.”

However, DiGiorgio worries that even if doctors no longer faced insurance barriers when making treatment decisions, patients might, as a result, encounter greater obstacles in receiving those treatments due to increased delays and access issues from a system covering the entire state population.

“If you look at how California administers this current insurance program, Medicaid, in my view, it doesn’t do a very good job,” DiGiorgio said. “Working at the safety net hospitals, I see how poorly Medicaid treats the medical patients. Obviously, I like working for them, and I’ll do everything I can to treat them, but they face a lot of obstacles that are really because of the way it’s financed. It creates some shortages and access to care, so patients who need a hip or a knee replacement have to wait two years to get those procedures done, whereas a privately insured patient has to wait maybe two or three weeks.”

These concerns are reflected in the actions of some major physician-led organizations. In fact, the California Medical Association, a nonprofit representing thousands of doctors across the state, recently endorsed Xavier Becerra, who is not in favor of the single-payer system.

“I suspect they know that it is going to be more restrictive for physicians in terms of the care that they can provide. It probably has to be, since it’s hundreds of billions of dollars that it’s going to cost the state annually, so for what people are going to be paying out to fund this, it may not come back in a way that keeps with what we’re used to doing and the medicine that we’re used to practicing,” Storey said.

Not only would previously insured patients see a difference in care, but so might those already under a government-funded program, according to DiGiorgio.

“I think by expanding the safety net, you often end up diluting it because if everyone is under the safety net, the people who need it the most have their voice a bit diluted. And so it ends up not working for them as well,” DiGiorgio said. “We have pretty much close to universal coverage with Medicaid, so I would much rather we focus on reforming it as a safety net, and then empower people who can to exit and get private insurance.”

As the debate over CalCare continues for the next session, Feresten reminds that any change, big or small, will help drive a broader movement across the country.

“There’s a saying that says, ‘As California goes, so goes the nation,’ which is why it would be very powerful for California to pass it. This is how Canada got their single-payer system. It was passed in one province, and then from there, their country followed,” Feresten said.