healthcare

Supporters of a half-cent sales tax proposed to help fund health services in Los Angeles County declared victory Tuesday after days of steadily gaining ground as more ballots were counted.

The latest results show the “yes” camp ahead by a slim margin, with just more than 50% of the vote. The measure needs a simple majority to win.

“Today, Angelenos sent a clear message: we take care of each other,” said Jim Mangia, chief executive of St. John’s Community Health and a spokesperson for the campaign, in a statement. “For months, we watched Washington make decisions that stripped healthcare away from hundreds of thousands of our neighbors — and today, Los Angeles County answered.”

The campaign said it would be organizing a news conference Wednesday to celebrate the “historic win.”

The proposal, on the ballot as Measure ER, had gained traction since election night, when results showed the tax had failed to gain a majority of support among early voters. Voters have not rejected a sales tax hike in L.A. County since 2012, when a transportation measure fell just short of a needed two-thirds majority with 66.1% support.

Approval of Measure ER would impose a new sales tax of half a penny of every dollar spent in the county, with the proceeds going to local hospitals and clinics that say they’re bleeding funding after federal cuts. Officials anticipate it will bring in $1 billion annually to patch the holes in the health services network.

The tax, which was championed by a coalition of healthcare advocates, takes effect Oct. 1 and will last for five years.

Los Angeles County’s half-cent sales tax to fund healthcare services was trailing Tuesday, with early returns showing a majority of voters rejecting the measure.

The tax — a half-penny of every dollar spent in the county — is meant to prop up local hospitals and clinics that are hemorrhaging funding after recent federal cuts.

The sales tax, which needs a simple majority to pass, would take effect Oct. 1 and last five years. Officials say it would pull in $1 billion annually to help plug the budget holes hitting local hospitals and clinics.

L.A. County health officials anticipate the One Big Beautiful Bill Act, signed into law by President Trump last summer, will slash more than $2 billion from the county’s health services budget within the next three years. Due to eligibility changes, the county will no longer be able to get reimbursements for many Californians who have lost Medi-Cal.

The measure was championed by a coalition of healthcare advocates called Restore Healthcare for Angelenos who warned that mass layoffs and emergency room closures could be imminent if new funding didn’t come fast. The Department of Public Health recently closed seven clinics — a grim sign, supporters said, of service cuts to come.

Voters haven’t rejected a sales tax hike since 2012, when a transportation measure fell just short with 66.1% support. It needed 66.7% to pass.

A majority of county supervisors had supported the new tax proposal, voting 4 to 1 this February to put it on the ballot. But the measure faced significant opposition from local cities, with opponents arguing the sales tax hike would unfairly burden the poorest county residents and encourage people to spend their dollars across the county line.

Supervisor Kathryn Barger, the board’s lone opponent of the tax, said she was concerned it was a “general” tax, meaning the money wouldn’t be earmarked for healthcare costs. Instead, she argued, politicians would have final say over how the money gets spent.

The supervisors have created a plan for spending the tax money, with the largest chunk of the money meant to cover the costs for patients without insurance. The measure also asked voters to sign off on a nine-member oversight committee.

The county currently has a base sales tax rate of 9.75%, and cities impose local taxes on top of that.

BAKERSFIELD — The southern Central Valley is home to one of California’s few remaining congressional battlegrounds, where Democrats are itching to oust longtime Republican incumbent Rep. David Valadao.

Last year’s voter-approved Proposition 50 redrew the lines of this Latino-majority district slightly in Democrats’ favor. Two top Democratic candidates are battling over who is the best choice to face Valadao (R-Hanford) in November.

Valadao is particularly vulnerable after he voted last year to cut Medicaid spending, a critical resource for many in this poor, rural area. Two-thirds of residents in the district are enrolled in the federally funded low-income health insurance program, and more than 60,000 are expected to lose coverage when work requirements and other federal rules take effect next year.

Rep. David Valadao (R-Hanford) leaves a meeting of the House Republican Conference at the Capitol Hill Club on March 17.

(Tom Williams/Getty Images)

National Democratic infighting has overshadowed a classic moderate vs. progressive primary race since House Democrats’ campaign arm threw its support behind one candidate, Assemblymember Jasmeet Bains (D-Delano), over Randy Villegas, a school board trustee backed by progressives including Sen. Bernie Sanders (I-Vt.).

The race was already tense when the Democratic Congressional Campaign Committee added Bains, a family doctor and two-term assemblywoman, to its “Red to Blue” program, which provides staff and fundraising support to Democrats running against vulnerable Republican incumbents. Local party leaders said they had received assurances from national Democrats that they would stay out of the race, which further angered Villegas and his supporters.

“This is another example as to why people’s faith in the Democratic Party and party leadership is at an all-time low,” Villegas said in an interview with The Times. “In many ways, it’s a badge of honor to not be the insider candidate and to say that I’m actually going to fight for community members here and not D.C. elites.”

DCCC chair, Rep. Suzan DelBene of Washington, cited Bains’ background as a family doctor and her track record in the Legislature fighting to expand access to healthcare.

Randy Villegas, running for California’s 22nd Congressional District, said his campaign manager wants him to take frequent selfies for their social media while walking neighborhoods in Bakersfield.

(Myung J. Chun/Los Angeles Times)

“We only weigh in on primaries when we feel that one candidate stands out as the strongest possible nominee to ensure that we win in the general election,” DelBene said in a recent interview on CBS’ “Face the Nation.” “This is a district that has been devastated by cuts to healthcare, a large Medicaid population, so she’s an incredible candidate and definitely can speak to the issues needed on health care.”

For Democrats, the outcome of the primary could have national significance. With President Trump’s popularity at a low point nationwide — and especially in California — the party hopes to win enough seats in the 2026 election to oust the Republicans from power in the U.S. House of Representatives.

Valadao, who was first elected to Congress in 2012, has been a perpetual target for Democrats, who have held a sizable registration advantage in his district. A moderate Republican, Valadao had emphasized his support for immigration reform, a departure from his party. Still, Democrats ousted Valadao in the blue wave of 2018, only for him to win back the seat in 2020 and remain in office ever since.

Both Villegas and Bains promote themselves as the Democrats’ best option to topple Valadao once again.

Villegas, the son of Mexican immigrants, is endorsed by the House Hispanic and progressive caucuses and has painted Bains as a corporate-backed candidate who would bend to special interests.

Jasmeet Bains, running for California’s 22nd Congressional District, speaks with Mary Jimenez during a campaign canvassing walk in Bakersfield.

(Myung J. Chun/Los Angeles Times)

“We can’t just offer that we’re not Trump. The Democratic Party actually needs to stand for something,” he said. “To me that means fighting for universal healthcare, universal childhood education, banning members of Congress from trading stocks, getting rid of corporate PAC money. Those things may make Democratic leadership uncomfortable, and I’m OK with that.”

Bains is campaigning on her experience as a physician in a region known for its poor environmental and health outcomes. After medical school, she returned to Kern County, where she completed her residency and continued working at clinics that primarily serve low-income patients in the region.

She decided to run for the seat after Valadao voted in favor of H.R. 1, the Republican spending bill Trump signed into law last year that cut nearly $1 trillion in Medicaid funding to pay for tax cuts, which Bains described as a “betrayal.”

“In the Valley, your word is your bond,” she said in a phone interview as she drove the 250-mile journey from her district to the state Capitol in Sacramento. “In the beginning he kept telling everyone that he wasn’t going to vote for it, and I took him for his word.”

Jasmeet Bains brings 8-month-old, Chiquita, as she campaign walks a neighborhood in Bakersfield.

(Myung J. Chun/Los Angeles Times)

Bains is the daughter of Indian immigrants and was the first South Asian woman elected to the California Legislature. She continues to work weekend shifts at a clinic in Delano.

“I thought the healthcare disparities of people losing their private insurance and having to transfer to Medicaid” was bad, Bains said. “With the trillion dollars cut from Medicaid federally, I’m now in a position where I’m transferring my patients from Medicaid to nothing. The problem in the Valley for healthcare has gotten worse and worse and worse.”

It’s the reason labor unions including SEIU Local 521, which represents workers in public, nonprofit and healthcare sectors in Kern and other counties around the state, are backing Bains.

“Within my own union, the members that I represent in Kern County, in certain ZIP Codes they have a 15-year less life expectancy than my union members living in Monterey County, which is a very similar community” with rural agricultural interests, said Riko Mendez, the union’s chief elected officer.

He said Bains understands the region’s unique health challenges and has used her perch in the Legislature to address them, including pushing for funding to research and treat valley fever, an infection caused by fungal spores in the region’s soils.

“We think her experience, her profile, her message is one that we agree with, and that has the best chance of winning in the runoff against Valadao,” he said.

Bains’ time commitments in Sacramento and working at the clinic leave her little time for a traditional campaign knocking doors and showing up to community events. Some voters backing Villegas have noticed.

Randy Villegas takes a phone call in the shade while walking neighborhoods in Bakersfield.

(Myung J. Chun/Los Angeles Times)

“For us, showing up is one of the most important things, and he’s the only candidate who has been doing that consistently,” 18-year-old Vanessa Orozco Romero said after a recent candidate forum in Bakersfield. Though nearly a dozen candidates for various offices were invited, Villegas and two other Democrats running for legislative seats were the only ones to attend.

Orozco Romero called the DCCC’s decision to back Bains “stupid and morally not OK,” especially since neither of the candidates earned enough delegate support to win the state party endorsement earlier this year.

Bains and Villegas have similar backgrounds as children of immigrants who grew up in the southern Central Valley. Though they both went on to earn high-level degrees, each is adamant about staying in Kern County to improve life for its residents.

The district is anchored in the eastern side of Bakersfield, home to California’s once-thriving oil fields, and stretches northward toward Fresno to include swaths of agricultural lands and small farming towns.

While there are more than twice as many registered Democrats in the district as Republicans, Democratic candidates often underperform in the Central Valley and independent voters play a crucial role picking winning candidates. Even under the new Proposition 50 lines that favor Democrats, President Trump would have beat former Vice President Kamala Harris by nearly 2 points.

Though nearly two-thirds of voters in the district are Latino, turnout is usually low among Spanish-speaking voters who are often discouraged by negative attack ads, Democratic activists said.

Save for the 2018 midterms during Trump’s first term, Valadao, a dairy farmer, has frustrated Democrats by continually winning over enough independents to hold onto the seat. Though the three candidates are competing in an open primary, Valadao is expected to advance to the general election as a longtime incumbent and the only Republican on the ballot.

“As he does in every primary election, Congressman Valadao is working hard to earn the vote of all Democrats, Independents, and Republicans,” Robert Jones, a consultant for Valadao’s campaign, wrote in an email. “We trust that the voters of the Central Valley will send the two best candidates to the general election in November.”

When Congress passed the big, ugly bill known as HR 1 last year, most Americans understood it meant cuts to Medicaid, the safety net program millions rely on for medical insurance.

But few Californians realized just how much it will affect the Golden State when its provisions really kick in, starting after the midterms (the Republicans aren’t that dumb) and continuing on in cascading cuts for the next few years.

Millions of Californians — not just low-income folks — are going to feel the effects, whether through a loss of insurance, fewer providers able to keep their doors open, or rising premiums and costs.

“This problem trickles up,” state Senate leader Monique Limón (D-Goleta) told me. “This is not just going to impact the people that have a public healthcare plan. When you see a hospital close, when you see medical providers no longer being able to practice, it is absolutely going to impact everybody, the middle class included.”

Added to the loss of federal funds, Gov. Gavin Newsom’s most recent budget plan (which the Legislature has to debate in coming weeks) includes cuts at the state level. This is in part to contend with the loss of federal money, but also because healthcare costs keep rising and even in this wealthy state, we can’t afford the bills — at least not without some changes.

What those changes are — and who should bear the brunt of them — is a complicated and largely ignored debate happening right now. While our candidates for governor have been grilled on whether they support single-payer healthcare or not, (Becerra is a sort-of, Steyer is a yes) the real question isn’t how is the next governor going to expand access to care — but how are we going to keep the whole system from collapsing right now.

“This is not hypothetical, this is what’s coming down the line,” Limón said.

The problem

About 15 million adults and children, or about 1 in 3 of our state’s residents, rely on Medi-Cal, which is what California calls its Medicaid program.

Through a creative bit of state financing called the Managed Care Organization, or MCO, tax, the federal government has been paying for a big chunk of the costs of that insurance, about $7 billion a year. President Trump’s HR 1 makes that money go bye-bye by greatly reducing the MCO, leaving the state to figure out how to backfill that cash. And that’s just one of the ways the big, ugly bill hurts California. Yes, it’s complicated.

The number of Californians losing health insurance coverage could roughly double in the next four years. Above, a patient undergoes treatment for tongue cancer at Ronald Reagan UCLA Medical Center on March 6, 2026.

(David McNew / Getty Images)

Newsom’s budget plan relies in a not-small way on restructuring the MCO tax to fit HR 1’s new rules. But here’s the problem with that — any fix will require approval from the Trump administration, which has repeatedly shown the welfare of Californians is not a high priority. In fact, the Trump administration in March rejected California’s request to update another fee related to hospitals that also generates billions for Medi-Cal.

So maybe Newsom will be able to negotiate a plan that saves the MCO and California healthcare. But wouldn’t it be much better for the GOP, with a presidential election looming, to watch California (and her presidential-contender governor) tumble off a healthcare cliff? Few states rely on an MCO tax the way ours does, which means our pain is going to be far more visible and profound if we lose this funding.

That means if Newsom’s budget is approved by the state Legislature with the MCO fix, the state is taking a gamble. If the feds don’t approve some new version of the MCO tax, “it would have major implications,” Adriana Ramos-Yamamoto told me. She’s a senior policy fellow with the nonpartisan California Budget and Policy Center.

Sort-of solutions

What’s the fourth-largest economy in the world to do? Limón would like to see the state stop subsidizing corporations who pay so meagerly that their employees qualify for Medi-Cal.

“We don’t have the luxury of being able to provide these tax subsidies,” Limón said.

Turns out, 42% of Medi-Cal enrollees are full-time workers, according to a new report by the UC Berkeley Labor Center. Although most big corporations offer some sort of health insurance, it’s often tied to working a certain number of hours (which they then make sure not to schedule) or it has prohibitive costs or other barriers.

In 2022, the Labor Center found, 34% of low-wage workers received their health insurance through employers, compared with 69% of higher wage workers — meaning California is picking up insurance costs because low-wage employers are finding ways out of them.

“Over the decades, Medi-Cal has really undergone a significant transformation. It’s shifted from a program that primarily served the disabled and indigent and elderly folks to one that largely supports folks that work in low-wage industries,” Tia Orr, the executive director of SEIU California, told me. “Medi-Cal has now become a program where folks that work every single day have to rely on it. The idea that someone can work every day and qualify for food stamps and Medi-Cal, it should be eye-opening to folks.”

Right now, she points out, California taxpayers are paying about $7,800 a year for each person on Medi-Cal.

“The corporations that they work for don’t have to pay one dollar of that, right?”

Limón and her Senate colleagues would like to change that. They have proposed the “Fair Share” plan that would impose a tax on the state’s largest and wealthiest corporations whose employees rely on public assistance. It’s more of an idea than a fleshed-out policy at this point, but as ideas go, it ain’t a bad one. It’s been done in Massachusetts, and New Jersey’s governor has suggested it.

In California, it deserves more attention than it’s currently being given.

To be fair, Newsom’s plan also would also limit state corporate tax credits to $5 million, as my colleague Taryn Luna points out, or 50% of a firm’s tax liability, whichever is greater. That change could bring in $850 million next year to state coffers and grow to $1.8 billion by the end of the decade. That’s still not nearly enough to cover healthcare costs.

To add to the drama, the California Legislative Analyst’s Office predicts all this will get worse — that the number of Californians losing health insurance coverage could roughly double in the next four years. The Newsom administration projects federal Medi-Cal changes could push off 44,000 people in 2026-27, growing to 1.3 million people by 2029-30.

That means more people getting sick and dying because they can’t afford a doctor. It means more doctors, clinics and hospitals losing income vital to keeping their doors open, and more emergency rooms being overloaded because it’s the only option.

“The worst is yet to come,” Rachel Linn Gish, interim deputy director at Health Access California, a consumer healthcare advocacy coalition, told me. “If you wait to take action until it gets bad, it’s already going to be way too late.”

She’s right, and however you look at it, a fix should include corporations paying their fair share.

What else you should be reading

The must-read: Justice Department sues UCLA for the third time, alleges antisemitism against students
The deep dive: The $400 Million Showdown Between a Billionaire and a California Mayor
The L.A. Times Special: Garden Grove crisis exposes Southern California’s hidden industrial risks

Stay Golden,
Anita Chabria

Was this newsletter forwarded to you? Sign up here to get it in your inbox.

Hundreds marched in Buenos Aires against President Javier Milei’s austerity policies and cuts to Argentina’s healthcare system. Protesters said funding cuts and rising costs are worsening access to healthcare and medicines and pushing the public health system into crisis.

SACRAMENTO — Human rights advocates on Tuesday rallied outside the state Capitol to push back on Gov. Gavin Newsom’s proposed budget plan to reduce state-sponsored healthcare coverage for undocumented immigrants.

“We are here to demand a budget that protects California’s values,” said Kiran Savage-Sangwan, executive director of California Pan-Ethnic Health Network. “We are fighting for a budget that rejects Medi-Cal cuts, seeks new revenues and strengthens our safety net reserve to keep families whole.”

Newsom last week unveiled his revised budget proposal, which would further move away from his previous policy to provide free healthcare coverage to all low-income undocumented immigrants.

His proposal would require monthly premiums for undocumented immigrants receiving coverage from Medi-Cal, the state’s version of the federal Medicaid program. It would also continue to block new adult applications, a cutback imposed last year.

The governor has explained that his original policy was more costly than expected and that difficult decisions must be made as the state could soon face an economic downturn.

Speakers at Tuesday’s rally argued this was unacceptable.

The cuts would force many immigrants to choose between putting food on the table or visiting a doctor, said Savage-Sangwan. She said certain groups, including refugees, older adults and those with disabilities, would be left especially vulnerable.

“These are the kinds of actions we would expect from a federal government that scapegoats immigrants and sends violent ICE forces to terrorize our community,” she said. “Instead, these proposals were made by our own governor in a state that claims to value immigrant communities. We know California is better than this.”

The governor’s office did not respond to a request for comment about the rally.

The event drew about 100 attendees, including Anahi Araiza, a policy researcher with Imperial Valley Equity and Justice. She told The Times that many immigrants in their community struggle to afford medical care and subsequently put off doctor visits.

“They wait until it’s an absolute emergency,” she said. “We’ve heard stories where people delay care and then get diagnosed with Stage 4 cancer.”

The event was supported by several organizations, including California Pan-Ethnic Health Network, Survivors of Torture International, Communities Organized for Relational Power in Action, Health4All Coalition, and Organizing Rooted in Abolition, Liberation and Empowerment.

One man carried a large sign with an image of the Virgin Mary that read “Safety Net For All.” Other marchers donned flowing monarch butterfly wings. The orange-and-black insect became a symbol for the pro-migrant movement years ago because it travels long distances between Mexico and the United States.

Meanwhile, another group gathered outside the Capitol for a news conference to raise awareness about the instability caused by federal healthcare cuts.

Assemblymembers Patrick Ahrens (D-Sunnyvale), Robert Garcia (D-Rancho Cucamonga) and Tina S. McKinnor (D-Hawthorne) joined several doctors and nurses to call for a $500-million state investment into public hospitals.

“Public hospitals are the backbone of our healthcare system,” Ahrens said. “It is estimated that federal cuts will strip over $3 billion a year from the California public hospital system — we cannot balance our budget on the backs of the most vulnerable Californians.”

The Republican-backed “Big Beautiful Bill” signed by President Trump last year shifted federal funding away from safety-net programs and toward tax cuts and immigration enforcement. During a legislative hearing this year, healthcare professionals warned state lawmakers the cuts would harm all patients, including those with private insurance.

It’s been years since Los Angeles County voters met a sales tax they didn’t like.

They agreed to pay half a cent more at the cash register to fund buses, trains and pothole fillings in 2016. The next year, they gave a quarter-cent more to fund homeless services. In 2024, voters bumped it up to a half–cent.

But with the electorate in a dour mood and reeling from rocketing gas prices, some speculate voters’ willingness to tax themselves may be dwindling as ballots arrive for the June 2 primary election.

“This is going to be a tougher year for taxes than prior years,” said former supervisor Zev Yaroslavsky, who pushed through a property tax ballot measure in 2002 to fund the county’s trauma care network. “There’s a limit to the tolerance people have for increasing their own taxes.”

Los Angeles County voters will soon decide whether they want to pay a temporary half-cent sales tax to shore up the region’s public healthcare system, which is facing dramatic federal funding cuts. Officials estimate the county will lose more than $2 billion in healthcare funding over the next three years.

The county currently has a base sales tax rate of 9.75%, and cities impose additional local taxes on top of that. If approved, the tax would take effect Oct. 1 and last for five years. The exact tax rate would vary depending on the city.

Voters haven’t said no to a sales tax hike since 2012, when a transportation measure fell just short with 66.1% support. It needed 66.7% to pass.

The healthcare sales tax has a lower bar to clear. The supervisors voted to put the measure on the ballot as a general tax, which gives them more leeway with how the money is spent and only requires a simple majority to pass.

But even that threshold may prove difficult. Polling from March suggested the measure was losing among L.A. city voters, who are often more generous than county voters at large. Angelenos will also find their ballot crowded with other tax hike proposals, which may leave some voters feeling picky.

“People have a very discerning instinct,” said Yaroslavsky. “They will pick and choose what they think is important.”

Despite no organized opposition, a flurry of cities, as well as the editorial board of the Los Angeles Daily News, have loudly spurned the idea, arguing it will make the region even less affordable.

“It’s just terrible timing,” said Paul Little, the head of the Pasadena Chamber of Commerce. “Costs are going through the roof for everything.”

With weeks to go until election day, healthcare workers and advocates supporting the measure have gone full steam ahead with mailers, marches and a social media campaign depicting a wallowing penny finding its lost sense of purpose with the measure. The campaign’s top funders are St. John’s Community Health and SEIU, who frame the measure as life or death for thousands of uninsured residents.

“Think about that person you know in your family who is asthmatic and relies on that inhaler, who has rheumatoid arthritis, who is diabetic,” said Supervisor Holly Mitchell at a recent town hall held in support of the measure. “And think about whether or not you’re willing to spend a half a penny — 50 cents on every hundred dollars — to make sure that that family, friend or neighbor gets what they need to be healthy.”

The supervisors voted 4-1 to put the sales tax on the ballot. Supervisor Kathryn Barger was the lone no vote.

Supporters say the One Big Beautiful Bill Act, signed by President Trump last July, is an existential threat to the public health system, leaving the county without reimbursement for the medical care of many Californians who are losing Medi-Cal coverage. The looming multibillion-dollar hole in the budget raises the prospect of hospital cutbacks, staff layoffs and possible emergency room closures, they say.

When Gavin Newsom ran for California governor in 2018, his support for a state-run single-payer healthcare system was considered a risky move and earned him hefty labor endorsements.

Today, leading Democrats in the wide-open race to succeed Newsom have embraced single-payer healthcare as a political necessity, an answer to voters fed up with rising premiums and other spiraling healthcare costs.

But with no clear front-runner, they are sparring among themselves in debates and political ads over who is most committed to a government-run model. No candidate has outlined how California would fund comprehensive health coverage for its 40 million residents, leaving voters unable to discern which candidate has a concrete plan for the nation’s most populous state.

Healthcare and political experts said the concept of single-payer has shifted from progressive pipe dream a decade ago to today’s mainstream talking points in a state where Democrats outnumber Republicans nearly 2 to 1. Democrats have pledged the model as the best way to lower costs in an attempt to woo voters worried about affordability as ballots arrive for the June 2 primary. The top two Republicans, meanwhile, have dismissed government-run healthcare as a “disaster” and “socialism.”

“In many ways, single-payer healthcare has become a progressive litmus test,” said Larry Levitt, a former White House policy advisor and a healthcare expert at KFF, a health information nonprofit that includes KFF Health News.

Few voters fully understand the term single-payer, let alone expect the next governor to achieve it, Levitt said. Rather, he added, the term has become more of a signal to voters about a candidate’s approach to healthcare reform.

Xavier Becerra, the former U.S. Health and Human Services secretary, who for decades backed single-payer healthcare in Congress, has come under criticism from opponents for a nuanced but clear shift away from single-payer. It came after Becerra secured an endorsement from the California Medical Assn., a powerful group representing doctors and a longtime opponent of single-payer healthcare bills in California.

At a May 5 debate put on by CNN, Becerra declared his support for “Medicare for All,” a proposal for a federally run system that’s been stalled for years, but he declined to say whether he’d pursue a California-led effort. He said his immediate focus would be on mitigating the drastic federal cuts expected to hit low-income and disabled enrollees in Medi-Cal, the state’s Medicaid program, which covers more than a third of residents.

Becerra is counting on voters not to distinguish between the often-confused terms single-payer, Medicare for All, and universal coverage, noting during the debate that “Californians don’t care what you call it, so long as they have affordable healthcare.”

“A lot of people aren’t clear what single-payer is, and they need a metaphor to understand it,” said Celinda Lake, a Democratic strategist and one of the lead pollsters for former President Biden’s 2020 campaign.

Billionaire activist Tom Steyer, who’s touted his self-funding as a signal he can’t be bought, has emerged as the race’s most vocal advocate of single-payer after opposing it during a short-lived 2020 presidential bid. As governor, Steyer has said, he would pass legislation backed by the California Nurses Assn. that has failed to come to fruition under Newsom’s tenure. Pressed on how he would cover the estimated $731.4-billion cost, Steyer told KFF Health News that “God is going to be in the details.”

At a forum last year, former U.S. Rep. Katie Porter said she didn’t believe achieving such a system was realistic in the near term, but the Orange County Democrat later told party delegates that she would “deliver single-payer.” Former Los Angeles Mayor Antonio Villaraigosa and San Jose Mayor Matt Mahan, Democrats who are trailing their competitors in the polls, don’t support single-payer. The top two vote-getters — regardless of party — advance to the November general election.

Some of the most seasoned politicians have failed to deliver single-payer. Newsom, who campaigned on the promise of being a “healthcare governor,” dialed back his ambitions upon taking office, choosing instead to pursue “universal access” to health coverage under a series of Medi-Cal expansions and efforts to contain healthcare spending.

The campaign bus for billionaire activist Tom Steyer, who has made single-payer healthcare a central pillar of his run for governor, in downtown Oakland.

(Christine Mai-Duc/KFF Health News)

Vermont, which remains the only state to pass a single-payer healthcare law, reversed course when leaders there couldn’t identify a funding source.

To enact single-payer, California would need permission from the federal government to redirect billions of dollars from Medicaid, Medicare and other funding that currently flows to the system — approval not likely to come from the Trump administration.

More than half of adults nationally say healthcare costs will have a major impact on whom they vote for in November, according an April KFF poll.

Danielle Cendejas, a Los Angeles-based Democratic consultant who works with state legislative candidates, said single-payer healthcare increasingly appears on candidate questionnaires from small-business advocates as well as hyperlocal Democratic clubs, in state legislative races and national union endorsements. What most California voters want to hear, Cendejas said, is how candidates plan to give them more immediate relief from higher premiums, expensive drug costs and long waits to access care.

The high price tag doesn’t faze Jennifer Easton, a 63-year-old Democrat from Oakland, who said other countries with similar models have proved they can lower costs. She said she supports a single-payer health system because it’s clear to her that Americans have reached the limits of working within the existing system. But she isn’t expecting any of the current candidates to succeed in implementing one, and she hasn’t decided whom to support.

“No one can in four years,” she said. Seeing a candidate enthusiastically support the concept gives her a good idea of their philosophy. “It is, if we’re lucky, a 20-year, 25-year plan.”

Rob Stutzman, a Republican political consultant who advised former Gov. Arnold Schwarzenegger, said while Americans may be supportive of single-payer in polls, focus groups suggest that approval drops quickly when voters realize it could mean losing their current doctor or insurance plan.

At the CNN debate, Steve Hilton, the Republican candidate President Trump has endorsed, said Californians would end up with subpar patient care and “taxes sky high to pay for it,” like in his native United Kingdom. Instead, Hilton suggested the state stop providing “free healthcare for illegal immigrants who shouldn’t even be in the country in the first place.”

Mai-Duc writes for KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism.

SACRAMENTO — One of Gavin Newsom’s top goals as he winds down his final year as California governor is to leave the state with a balanced budget.

After years of the state spending more money than it brings in, it’s Newsom’s last opportunity to fix a chronic deficit or dump the problem on the next governor.

How far he goes to solve the state’s structural spending imbalance will define his legacy as a steward of trillions in taxpayer dollars. As a potential candidate for president in 2028, he could also have a political incentive to do as little as possible.

“Any cuts you make are going to cause people to scream,” said Darry Sragow, a veteran Democratic strategist. “Any increases in taxes are going to cause people to scream and in terms of what’s best for a presidential run, it would be nice if people weren’t screaming.”

As California’s 40th governor, Newsom expanded publicly funded healthcare to income-eligible undocumented immigrants, increased state-subsidized child-care slots and provided free meals for schoolchildren among a wishlist of progressive wins since he took office in 2019.

His achievements have helped struggling Californians live in an increasingly unaffordable state and given him bona fides to tout to voters if he launches a bid for the White House.

But the state could never afford to pay for existing services and the new programs that Newsom and Democratic lawmakers enacted, according to an analysis of ongoing state spending since before the pandemic released by the Legislative Analyst’s Office last week.

Spending from the state’s principal operating fund has grown about $100 billion since Newsom’s first full fiscal year in office in 2019-20, mostly due to the growing cost of existing programs that he inherited. State spending has outpaced California’s strong revenue growth by about 10%, creating a perennial budget shortfall — a structural deficit — that Newsom and the Democratic-led Legislature solve with largely temporary fixes each year.

Instead of making across-the-board program cuts or raising taxes to align spending with revenue, Democrats have tapped into reserves designed to preserve social services for the state’s most disadvantaged communities during economic downturns.

While the California economy remains stable and state revenue has increased, Newsom and lawmakers have taken $12.2 billion from the rainy day fund. Democrats have borrowed $28 billion more from other state funds to cover their spending in recent years, according to the LAO.

“Taken together, these trends raise serious concerns about the state’s fiscal sustainability,” Legislative Analyst Gabriel Petek wrote in a review of Newsom’s January budget proposal.

Fiscal watchdogs have warned that the spending trends will leave California in a precarious position if the stock market tanks and tax receipts bottom out.

Personal income taxes are driving higher-than-expected revenue now, which analysts attribute to an artificial intelligence boom on Wall Street, and suggest the state could have no deficit in the upcoming year. In January, the Newsom administration anticipated significant operating deficits in the years ahead: $27 billion in 2027-28, $22 billion in 2028-29 and $23 billion in 2029-30.

The LAO, the Legislature’s nonpartisan fiscal advisor, said the state has already solved $125 billion in budget problems over the last three years with mostly short-term solutions.

“This issue is really whether they’re going to take seriously the structural deficit that is several years in the making now, where the spending has outpaced revenue, and to address that, they’re going to either have to make some fairly deep cuts or raise revenue and or both,” said former state Controller Betty Yee, who worked as a budget aide under Gov. Gray Davis and recently dropped her own campaign for governor. “But they have to be real. I think resorting to these one-time solutions has really exacerbated the problem.”

How Newsom wants to address the state’s financial challenges will be revealed on May 14 when he is expected to present his revised budget plan in Sacramento. His January budget proposal did not include any significant reductions or cuts to programs.

H.D. Palmer, a spokesperson for the California Department of Finance, said the governor is looking to solve the budget problem with more than a temporary fix.

“Although he is still finalizing his proposal that he’ll put forth to the Legislature, as he has said, he wants those solutions to be durable, and he wants them to have an impact beyond a single fiscal year,” Palmer said.

To stabilize California’s budget, Democrats will probably have to raise taxes or fees to generate new revenue and cut programs, according to the LAO. At least 40 cents for every dollar in revenue is dedicated to education under the state Constitution, requiring policymakers to find between $30 billion and $60 billion annually in additional revenue to cover projected shortfalls in 2027-28 and beyond if relying on new taxes alone.

President Trump’s cuts to healthcare are adding to the problem.

HR 1 will add $1.4 billion in state costs to the general fund. Newsom’s January budget proposal did not include a plan to help millions of low-income Californians who are expected to lose access to healthcare under the federal cuts.

To temper those cuts in California, other groups proposed a new tax on billionaires that appears poised to qualify for the November ballot.

Spearheaded by Service Employees International Union-United Healthcare Workers West, the initiative would apply a one-time 5% tax on taxpayers with assets exceeding $1 billion. If approved by voters, the tax would generate roughly $100 billion, which would fund healthcare programs.

The measure has divided unions and Democrats at the state Capitol.

Newsom has criticized the initiative, citing concerns that increasing taxes on the wealthy will have the opposite intended effect and drive the highest earners out of California. Under a progressive tax structure, the state budget is dependent on income taxes paid by the ultra-rich on earnings largely from capital gains.

Larry Page and Sergey Brin, the co-founders of Google, have already purchased residences in Florida, along with others looking to escape the tax if it goes through in November. Billionaires launched their own ballot measure campaign to undercut the tax proposal.

State lawmakers are also considering avenues to raise revenue, which include repealing a “water’s edge” tax break. Under the change, multinational companies would no longer be allowed to shield the income of their foreign subsidiaries from state taxes. California loses about $3 billion in revenue from the tax break each year.

In its budget plan released in April, the state Senate proposed a new fee on the largest corporations in the state to provide $5 billion to $8 billion annually for Medi-Cal.

The upper house said 42% of Medi-Cal enrollees are full-time workers who are not enrolled in their company’s healthcare plan because their wages are low enough to qualify for state-subsidized healthcare. As a result, corporations aren’t paying for healthcare for many of their employees and instead taxpayers are picking up the bill through Medi-Cal.

SEIU California, the powerful state union council representing over 700,000 workers, endorsed the plan. The union said Trump’s tax policy will reduce corporate taxes by $900 billion, while 3 million Californians lose healthcare.

“In this urgent moment, California’s workers need to see our leaders show us what they’re made of,” said Tia Orr, executive director of SEIU California. “The Senate is showing the courage to demand corporations pay their fair share, rather than making working people pay with their lives.”

The change is being described as a more politically palatable “fee” and not a tax.

“We explored multiple revenue options, and this was the one that felt more narrow, it felt more focused, and it also felt like it was directly going for the subsidy that’s being lost because of the Trump HR 1 cuts,” said Senate President Pro Tem Monique Limón (D-Goleta), who leads the upper house of the Legislature.

Limón said her caucus believes it’s important to address potential revenue streams because of the depth of federal healthcare reductions.

“If we don’t address the structural deficit, we are looking at severe cuts,” she said. “You are looking at people without health insurance. You are looking at hospitals closing down. You are looking at medical providers not being able to take more patients. You are looking at our emergency rooms over capacity, with not enough medical providers. I mean, you’re looking at a place that’s really, really, really difficult, and we feel like we have to, at least, look at what are viable options that are conditional on these cuts coming.”

Newsom has not commented publicly on the Senate’s plan. As governor, he’s been reluctant to embrace new taxes and fees.

Newsom could reject all the proposals for new taxes or fees and continue what he’s done before: take advantage of higher-than-expected tax collections, shift funds around, delay program implementation and borrow money to knock the deficit down to zero, or forecast a surplus, for his last budget year that begins July 1.

If he doesn’t take on California’s larger budget imbalance, then the problem would be the next governor’s to solve. A stock market crash, or economic recession, could force his successor to make drastic cuts across the board with limited reserves to support programs.

Kicking the can again would cement Newsom’s fiscal legacy as a governor who championed bold headline-making policies that bolstered the safety net for low-income Californians, but who failed to provide a solution to pay for his agenda.

“Not only has he not come up with a plan, he has pretended we don’t need one,” said Patrick Murphy, a professor of public affairs at the University of San Francisco.

Newsom’s interest in running for president could seemingly discourage him from slashing the budget and raising attention to the state’s financial woes, Sragow said. Newsom is setting himself up as a potential front-runner for his party. He has said he remains undecided about officially launching a 2028 campaign.

As a Democrat from California, his opponents would automatically label him as financially irresponsible and tax-happy. Calling out the massive budget problem on the horizon, raising taxes and making painful cuts will give them ammunition.

“There’s a long list of things that he’s going to be charged with, and this is likely to be one more,” Sragow said. “But I guess the question is, is he going to be charged with a political misdemeanor or a political felony?”

Former state Sen. Steve Glazer said Newsom is standing on political quicksand either way. State budget projections are based on assumptions about the future that often don’t bear out, leaving his choices exposed to criticism that he went too far, didn’t do enough, and everything in between.

“Whatever the governor decides to do in his May revise and in his final budget, it’s fraught with political risks, because it can be manipulated so easily by all sides,” Glazer said.

If Newsom ignores the spending problem, his successor could blame him for California’s financial woes when they take office in January and provide their own outlook of the state’s fiscal future. At the time, Newsom could be trying to convince America to make him the nation’s next president.

Murphy said Newsom has championed major policies and been reluctant to back off them later when revenue doesn’t pencil out.

In terms of spending, he’s governed similarly to the men who led California before him, with the exception of Jerry Brown, who cut programs to reduce a deficit he inherited in his second stint in the governor’s office and left Newsom with a surplus.

“It’s not all that different than most of the governors have done, which is finding it very hard to say no and finding it very hard to take on a tough choice of going to the ballot to ask for more money or raise taxes,” Murphy said.

On taxation, Newsom is perhaps most similar to former Gov. George Deukmejian, who opposed general tax increases for most of his administration.

Deukmejian left a budget disaster for his successor, Gov. Pete Wilson. Deukmejian publicly claimed he passed a balanced budget in his final year and blamed an economic downturn for the problems Wilson encountered.

When Wilson announced a record $13-billion budget deficit early in his first year in office in 1991, he said the Persian Gulf War, an economic downturn and natural disasters added to a structural deficit in the budget.

The Legislature and Deukmejian, Wilson said, had “papered over” the problem.

Supervisor Kathryn Barger was the only supervisor against it. She pointed to the fact that the tax was a “general” tax, meaning the money won’t be earmarked for healthcare costs. That means politicians have final say over how the money gets spent rather than voters, she said.

Some cities within L.A. County say they’re also rattled over the tax, unleashing a stream of opposition letters against the tax. The California Contract Cities Assn. argues a sales tax hike would “disproportionately burden the very residents the County seeks to protect.” Shoppers near the county line, they warn, likely would start crossing it to shop.

Some of these cities say they have the trust issues when it comes to county ballot measures. When voters approved Measure B in 2002 to fund the county’s trauma center network, an audit years later found the county couldn’t account for whether the money actually had been spent on emergency medical services. And some cities feel they never got their fair share of funds from Measure H, the homelessness services tax measure passed in 2017.