medicare

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.

WASHINGTON — House Republicans on Thursday shut down an inquiry by Democrats into whether the Bush administration acted illegally or inappropriately last year when it withheld from Congress its estimates of the true cost of the Medicare prescription drug bill.

At issue are allegations that then-Medicare Administrator Thomas A. Scully threatened to fire his top actuary if he gave lawmakers his analyses showing the costs would be much higher than administration officials were saying publicly.

Thursday’s conclusion of a Ways and Means Committee hearing all but ensured that two individuals central to the controversy — Scully and White House aide Doug Badger — would not testify before Congress.

Separately, the Health and Human Services Department is conducting an internal investigation into the matter, and Democratic lawmakers have requested civil and criminal inquiries.

Democrats on the Ways and Means Committee had asked Scully and Badger to answer questions about when President Bush and top-ranking officials were told that internal estimates of the Medicare bill’s cost were more than one-third higher than the $400 billion Bush had set aside, and why those analyses had not been shared with lawmakers.

But White House Counsel Alberto R. Gonzales, in a letter to committee Chairman Bill Thomas (R-Bakersfield), cited “long-standing White House policy” against having White House staff members testify before Congress as the reason Badger would not appear.

And Scully, now a private consultant, said in a letter to Thomas that he was unable to appear before the committee because “unfortunately, for the past ten days I have been traveling.”

Committee Democrats rejected both explanations. In the case of Badger, they said at least 45 high-ranking Clinton administration officials had testified before Congress; in the case of Scully, they offered to let him appear at a later time. But Republicans quashed the Democrats’ attempts to subpoena the men.

Republican committee members accused the Democrats of trying to capitalize on the controversy, which erupted last month when Medicare actuary Richard S. Foster told reporters that Scully had threatened to fire him if he responded to Democratic requests for analyses of the pending legislation.

Thomas, the committee chairman, said that although he was willing to use “whatever tools are necessary to get to the bottom of a violation of law,” he was not willing to issue subpoenas to Badger and Scully “to satisfy someone’s whim or curiosity.”

As for preliminary estimates by Foster indicating that the Medicare bill could cost as much as $551 billion over 10 years, Thomas said the information “probably would not have enlightened Congress as much as confused Congress.” Thomas chaired the House-Senate conference committee that completed the legislation.

In January, the Bush administration revised the estimated cost of the Medicare overhaul to $534 billion.

Democrats, who noted the original Medicare bill passed the House in June by one vote, charged that a broader constitutional issue was at stake: How far can the executive branch go in withholding information from Congress that could affect the outcome of a vote?

In November, a narrowly divided Congress passed the Medicare bill, which created a new prescription drug benefit and gave private insurers and drug companies billions of dollars to lure seniors and the disabled into managed care plans.

Several conservative Republicans, who were concerned about the bill’s projected $400-billion cost, voted for the legislation only after high-pressure lobbying by Bush and Health and Human Services Secretary Tommy G. Thompson.

“The main issue is who knew about the actuarial figure, and why wasn’t it disclosed in a timely fashion?” said Rep. Sander M. Levin (D-Mich.). “There was a cover-up of this information and we want to know how high the cover-up went.”

Procedural maneuvering and partisan wrangling dominated much of Thursday’s hearing, which was more than half over before its two witnesses began their testimony.

Jeff Flick, regional administrator of the Centers for Medicare and Medicaid Services in San Francisco, confirmed that while serving as Scully’s special assistant he composed an e-mail to Foster that reiterated Scully’s insistence that Foster withhold information requested by Rep. Pete Stark (D-Hayward).

“The administrator emphasized that if Rick does not adhere to these instructions, it is outright insubordination and insubordination carries serious consequences,” Flick said, adding that Scully’s “actual language may have been more colorful.”

Scully, who has denied threatening to fire Foster, acknowledged in his letter to Thomas that “there is no question whatsoever that I made it very clear to Mr. Foster, both directly and indirectly, that I, as his supervisor, would decide when he would communicate with Congress.”

Leslie M. Norwalk, acting deputy administrator of the Centers for Medicare and Medicaid Services, told committee members that she had advised an anguished Foster that although his office was not legally required to share information with Congress, the office was subject to Scully’s authority.

Americans could be forgiven if they’re unaware that President Trump recently performed one of his most essential tasks and sent his annual budget request to Congress, though months late and stunningly incomplete.

After all, so much else has been dominating the news lately: the Mideast war that Trump promised not to start. Price rises he’d vowed to end. His repeated insults of Pope Leo XIV. His portraying himself as Jesus Christ, then lying about having done so. An incompetent attorney general to fire. And the president’s actual priorities — plans for a $400-million White House ballroom and a massive “Triumphal Arch” nearby!

It’s a lot.

Once again, as in Trump’s first term, the public and press are inattentive to the nation’s fiscal health relative to past years. But that reflects the president’s own disengagement with reconciling spending and revenue — this from a president many Americans voted for based on his purported prowess as a businessman. For decades back to Ronald Reagan’s time, so-called deficit wars in Washington were a big story. Now, even Republicans in Congress complain of Trump’s absence from the fiscal fray as they struggle to belatedly finish this year’s budget work that was due last fall, and to end a weeks-old partial government shutdown, before turning to the budget for the fiscal year starting Oct. 1.

Yet it’s worth paying attention to U.S. budgets even if Trump won’t, for the sake of our children and grandchildren who’ll inherit the bills. In one document, a federal budget reflects the nation’s priorities. And these days, in the perennial guns-versus-butter debate, Trump has made his feelings all too plain.

“We’re fighting wars,” he told a group at the White House on April Fools’ Day. “We can’t take care of day care … Medicaid, Medicare, all these individual things.”

Forget that Trump swore to end wars. Or that last year, long before he went to war against Iran, he cut $1 trillion over 10 years from Medicaid and other healthcare programs in his misnamed “One Big Beautiful Bill.”

Yes, budgets can be boring, especially to a president with a famously short attention span. Trump and many of us Americans are distracted constantly by all the shiny objects he throws at the national consciousness by his words, acts and social media postings at all hours.

Yet the budgetary trend is clear to anyone bothering to look: As president, Trump is once again exacerbating the nation’s unsustainable course of piling up debt. According to the nonpartisan Congressional Budget Office, among other credible sources, debt is now approaching the highest level in U.S. history, which was reached during World War II. It already surpasses the size of the entire economy and threatens higher borrowing costs and reduced investments.

For all the achievements Trump likes to claim — ending eight wars in a year! — here’s one that’s real: He is on a path to break his own record for the most debt in a single presidential term, $8.4 trillion in Trump 1.0, which was nearly double the increase under President Biden.

Need further proof of Trump’s brazen mendacity? Of course you don’t, but here it is: In the face of the well-documented budget record, Trump declared both this year and last year to a joint session of Congress, on national television, that he would balance the federal budget —“overnight,” he said in February.

The inequitable tax cuts and big spending increases for the military and immigration crackdowns that Trump and the Republican-controlled Congress enacted last year are significantly greater than in his first term, and are driving up the debt despite Republicans’ deep healthcare cuts. Just months after Trump took office, the ratings firm Moody’s downgraded the nation’s sterling credit rating for the first time in more than a century.

And now, in his new budget request, Trump seeks to inflate military spending from under $1 trillion when he regained office to $1.5 trillion, for the biggest year-to-year increase in military budgets since World War II.

This fiscal irresponsibility is happening at the worst possible time. For the last quarter of the 20th century, presidents and Congresses of both parties annually debated how to reduce deficits and several times reached consequential multi-year deals, culminating during the second Clinton term in four straight years of surpluses. (Those surpluses ended — wait for it — with Republicans’ tax cuts and war spending during the George W. Bush administration.)

Politicians back then were moved not just by the deficits of their time — deficits that, as a share of the economy, were less than half what they are now. They also were responding to experts’ warnings of a demographic tsunami by the 2020s: With the aging of the huge baby-boomer population, spending for Social Security, Medicare and Medicaid would greatly increase even as the workforce whose payroll taxes support those programs shrank. Today the number of people 65 or older is almost three times what it was 50 years ago, and rising.

This reckoning is upon us, though you wouldn’t know it as Trump keeps calling for cutting revenue and spending more for lawless wars, immigration raids and monuments to himself. Barring bipartisan action, in 2033 Social Security’s retirement fund and Medicare’s hospital fund will no longer be able to cover beneficiaries’ full claims, according to their trustees’ annual report, necessitating reduced benefits or shifts of money from other worthy programs.

Trump did put Vice President JD Vance in charge of a “war on fraud.” But that holds about as much promise as Elon Musk’s fiscal fiasco — remember DOGE? — that cost money instead of cutting $2 trillion as promised.

Like other problems, Trump likely will leave the fiscal follies to his successor, who, should he or she win two terms, would preside as Social Security and Medicare become insolvent. I’ve yet to hear any of the early 2028 presidential aspirants — or Trump — address or be asked about that.

Let the debate, belatedly, begin.

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WASHINGTON — Reviews to detect Medicare overpayments were done on fewer than 1% of the doctors who bill the federal health insurance program, a congressional investigator said Wednesday.

The reviews by Medicare’s private contractors are an important way to identify physicians who have been paid too much to treat the elderly and disabled, auditor William Scanlon said at a House Budget Committee hearing.

In the 2000 budget year, those private contractors reviewed the medical claims of 1,891 physicians out of more than 600,000 who billed Medicare that year, said Scanlon, who covers health issues for the General Accounting Office, the investigative arm of Congress.

Most Medicare payments are proper, Scanlon said. But the program “faces a difficult task in finding an appropriate balance between ensuring that Medicare only pays for services allowed by law and making it as simple as possible for providers to treat Medicare beneficiaries and bill the program.”

In 1999, payments made in error amounted to $11.9 billion, the government has reported.

At the hearing, government and academic experts said Congress should pay more attention to the financial health of the 36-year-old program. Government projections earlier this year predicted Medicare, a $240-billion program, would start running short of cash in about 15 years.

An official at the agency that runs Medicare promised a turnaround on all counts.

“In no way will we diminish our interest in fighting waste, fraud and error in the Medicare program,” said Ruben J. King-Shaw Jr., the chief operating officer for the Centers for Medicare and Medicaid Services.

“For the small percentage of people who take advantage of the system, we will continue our aggressive efforts to protect the funds that taxpayers have entrusted to us.”

Financial experts also told Congress that the goals of overhauling Medicare and adding a popular prescription drug benefit could be too much all at once.

“Medicare’s future will likely be written numerous times as health care changes and baby boomers move through the system,” said Marilyn Moon, a health economist at the nonpartisan Urban Institute.

There were also warnings about encouraging private health plans to compete with the federal program. President Bush promoted the idea this month.

Bush said he wants more health maintenance organizations and private health plans to compete for seniors’ business within the underlying Medicare program; 15% of the 40 million enrollees use private plans. Bush said such competition could bring better service, lower premiums and extra benefits, such as complete drug coverage.

But the government would have to make sure it helps all seniors, regardless of which plan they are in, said Comptroller General David Walker, head of the GAO.

“Separating winners from losers is a basic function of competition,” Walker said in a report to Congress.