WHILE more than 15 years ago, still vivid in my memory is a prescient conversation I had with Rob Restuccia on the prospects of health reform. Rob, as the longtime director of Community Catalyst and a key architect of the national health care reform movement of state advocates, was talking with me and John McDonough, one of his successors as head (then) of Health Care for All Massachusetts. We were comparing the similarities between the activities in Massachusetts and California where proposals for employer mandates, Medicaid expansions, insurance market reforms, and single-payer were all being considered. We also discussed how our states' Republican governors might be obstacles, and where they might be allies.
Beyond that, Rob helped map out how these state actions could be a springboard for federal health reform. This was striking since this conversation took place during the Bush years, well before any presidential candidacies were announced, before any federal legislation was introduced or named, and before any big breakthroughs at the state level, and yet we were already doing vote counts on which swing Senators (Snowe and Collins of Maine? Smith of Oregon?) might be willing to support which type of federal health reform.
What happened years later in 2009 and beyond is a testament to Rob's vision and the work he did to bolster advocacy at the state level, knowing that it would lay the groundwork for the potential for federal health reform in the future—even if no one could predict what that would be.
The rest is history: Governor Romney and his Massachusetts Legislature eventually did pass a landmark health care law, which formed the framework for the discussion in the Democratic presidential primaries and ultimately the Affordable Care Act (ACA) itself. On the opposite coast, after initially saying no to a number of proposals in California, then-Governor Schwarzenegger took inspiration from Massachusetts and sought his own “year of health reform.” Although that effort stalled, it laid the groundwork for California's efforts to implement and improve on the ACA.
As an incubator for progress, Massachusetts and California have provided leadership in the country's health reform journey. Now today, as presidential candidates vigorously debate “Medicare for All,” ACA improvements, and the path for the next wave of health reform, states can once again lead the way. In California especially, where single-payer health reforms have been debated years before the current federal debate, we have already learned the lesson that it does not have to be either comprehensive reform OR building on existing structures: we can, and should, do both.
The resurgence of grassroots energy in California was evident when the ACA came under attack in 2017. But the energy was not just about defending our health system from the worst but also in the pursuit of positive reforms to achieve the best. The “Medicare for All” ideal has great appeal, for its universality, security, and simplicity, and it is something my organization has supported for more than 30 years. Yet, we are realistic about the barriers that need to be overcome—not just industry opposition but also voters' natural concerns about change, and procedural issues such as the need for federal approvals at the state level, and the need for a 60-vote supermajority in the US Senate. When a single-payer bill stalled in the last legislative session—largely due to lack of detail in answering those questions—the California Legislature created a Council on Health Delivery Systems to begin planning the work needed to pursue a unified financing system.
Also in 2018, more than 70 consumer and constituency groups came together to win “Care for All California” with an aspirational agenda that was achievable in the near term, without federal approval. We laid out a path that was explicitly complementary—not competing—with the goals of more comprehensive reforms. To cover most of California's 3 million remaining uninsured, we must address that roughly half are undocumented, and thus excluded from public programs, and the other half simply struggle to afford their care and need greater affordability assistance.
California's new Democratic Governor, Gavin Newsom, has relevant experience to share in these debates. As mayor, he presided over the passage of Healthy San Francisco, providing universal access to care in his city, in the same year as the Massachusetts' reforms. While the Massachusetts law was the main framework for the ACA, San Francisco contributed to the debate with its model (as well as with the leadership of Speaker Nancy Pelosi). In the intervening years, Newsom campaigned in support of the ACA and spoke positively of a Medicare for All vision in his gubernatorial campaign in 2018.
On his first day in office, Governor Newsom laid out a path similar to what advocates have been pushing for many years, not either/or but yes/and. Hours after his inauguration, Newsom sent a letter to the federal government, asking for the unprecedented waivers needed to set up a state single-payer system. But with a federal government hostile to health care in general, and California in specific, he did not wait to take additional actions to provide more help, sooner.
Governor Newsom proposed a state prescription drug purchasing pool aimed to address health care costs and named California's first-ever Surgeon General. On top of those key efforts, Newsom proposed several steps to build on the ACA and expand coverage in California. He would reinstitute the ACA's individual mandate penalty at the state level—an action that has already lowered premiums in New Jersey. He would use the money raised from the penalty to increase affordability assistance in the individual market. Under his plan, California would be the first state to provide financial help to middle-income families at 6 times the poverty level, a necessary inclusion in our high-cost-of-living state.
Our Governor took another historic step by proposing to expand our Medicaid program to cover all income-eligible young adults up to the age of 26 years, regardless of immigration status. This would build on California's recent expansion of Medicaid, joining 5 other states to cover all children. This expansion would ensure these Californians do not lose coverage for their 19th birthday. If this move in enacted, California would be the first state in the nation to cover an adult undocumented population beyond pregnant women.
These are ambitious plans—and health advocates are working to make sure they are implemented, as well as pushing beyond to see what additional investments we can make for a full “down payment” toward universal coverage. Under the ACA, California has cut the uninsured rate in half from nearly 20% to 7%, decreasing the number of uninsured Californians from 7 million to around 3 million. We want to help Governor Newsom and the legislature achieve universal coverage in the next few years, bringing the uninsured rate to 5% or less, the level where many other developed nations with universal health care systems are.
This immediate agenda does not stand in place of broader reforms. In reality, these are the building blocks of these reforms, just as Rob Restuccia envisioned all those years ago. State advocates can push for these and other steps that keep the health industry accountable for costs, quality, and equity. For example, Massachusetts is continuing to work to improve its cost commission passed in the wake of its coverage expansion and last year California advocates proposed a rate-setting commission that even went farther. That specific proposal stalled last year, but the work continues to contain costs, using the regulatory or purchasing power of the state, as a single payer or in other ways until then.
As laboratories of democracy, state policy makers and advocates can model not just the policies to consider at the federal level but also the vocabulary and the strategy for success—embracing complementary strategies of short-term success and long-term planning and progress toward a compelling vision. Rob spent his career cultivating state-based health advocacy, erecting the infrastructure for the fight going beyond his lifetime, to achieve the vision that health care is a right for all. In part because of his prescience and capacity-building prowess, Massachusetts, California, and other states may once again be the inspiration for federal reform and lead us ever closer to the ultimate goal of quality, affordable health care for all.