A representative of Health Care for All, a group that supports a single-payer coverage system, talks to people attending a recent California Democratic Party convention in Sacramento. Photo by Laurel Rosenhall for CALmatters

Should state government become the health insurer for all Californians? With support for that idea growing amid federal efforts to dismantle the Affordable Care Act, the state Senate passed a measure Thursday that would create a new state agency to oversee health care and pay providers directly, eliminating premiums and co-pays for patients.

Similar proposals have been made before — even passed the full Legislature, then fell short of gubernatorial approval. Proponents hope this year will be different, given the new momentum for a healthcare overhaul and the support of powerful unions.

But the measure has a long way to go, facing the same challenges that bedeviled earlier efforts: cost, a skeptical governor, deep-pocketed opponents and the need for certain federal approvals.

State Senators Ricardo Lara of Bell Gardens and Toni Atkins of San Diego authored the “single payer” proposal that now goes to the Assembly. They say California today can be a leader on universal health care, while Congress regresses by attempting to repeal the Affordable Care Act and change Medicaid funding.

“We are on a collision course for rising health care costs and a crisis for California’s middle class,” Lara said while presenting the bill to his Senate colleagues. “The good news is that California will get a lot more for our money.”

The proposal, SB 562, would cover all California residents, including those without legal immigration status — a notable departure from previous efforts, although the bill lacks information about how much this group adds to the bottom line. Many such residents are already covered with public funds; a Senate Appropriations Committee analysis of the bill says 1.8 million undocumented adults are not covered under any program.

But that is the only substantive new provision. The bill has drawn criticism for lacking a guaranteed financing plan and for a hefty price tag: perhaps as much as $400 billion a year, more than twice the state’s entire budget.

The $400 billion figure came from the Senate committee, which Lara chairs, though at least one other analysis attached a much lower figure. The Democratic senator, who is a candidate for California insurance commissioner, has not yet issued a cost projection or a financing plan, although he says those are coming. The committee’s analysis said half the cost of the new system could be covered by money diverted from existing government programs such as Medicare and Medicaid — assuming federal waivers on those funds are granted. Most of the rest would likely come from new taxes.

The committee estimates a new payroll tax for this purpose could be 15 percent of earned income but offers no information about how such a tax might be split between employers and workers, or whether it would fall wholly on one or the other. And new taxes require a two-thirds vote of the Legislature — a tough ask despite Democrats’ domination of the statehouse.

Currently, Lara says, Californians spend $367 billion annually on their health care. He told the Senate on Thursday that his bill would cut expenses “through better administration and lower prescription drug costs. Having one publicly run system will reduce inefficiency and missed prevention opportunities.”

Lara will use a new financing study, commissioned by the California Nurses Association and released Wednesday, as a jumping off point for his own funding plan, according to his staff. The study, done by a researcher at the University of Massachusetts at Amherst, pegged the annual price at $331 billion, with savings culled from such areas as administration, pharmaceuticals and unnecessary services.

The study also says taxes could fund costs not covered by Medicare or Medicaid, through a new 2.3 percent fee on some businesses and a new 2.3 percent sales tax on non-essential purchases. Alternatively, the study outlines a potential new 3.3 percent payroll tax on both employers and employees, combined with the sales tax.

Even with the higher taxes, the study says, some California families could save as much as 9 percent annually on health care and some small businesses, as much as 22 percent (the largest employers might save 1 percent). The taxes would replace consumers’ premiums, co-pays, deductibles and other costs.

Supporters concede that funding is a challenge. But they say it’s surmountable with the government’s power to negotiate limited rates in a state the size of California, and with the elimination of insurance companies from the equation.

“We spend the money on hospitals and doctors and drugs already; the question is reorganizing those dollars,” said Anthony Wright, executive director of Health Access California, a consumer advocacy organization. “The money we spend already on taxes and through premiums and deductibles would be funneled into one payer.”

Large insurers such as Kaiser Permanente, Blue Cross and Aetna, for whom California is a huge market, strongly oppose the bill. So does the California Chamber of Commerce, which considers it a “job killer.” Those interests have well-paid lobbyists fighting the proposal in the Legislature, where some members may be on board with the concept but not necessarily this proposal, at least in its current form.

Business interests also say employers and workers would be hard pressed to absorb additional taxes.

“There’s a well-established reason that previous governors and other states have rejected such a concept — it’s poor policy,” said John Kabateck, president of Kabateck strategies and former California executive director of the National Federation of Independent Business. “Californians are already faced with some of the highest tax burdens in the nation.”

Beyond the cost and tax issues is the question mark that hovers over federal waivers. President Trump has said little about single-payer health care since he took office. But he has railed against California’s opposition to his administration, saying the state “is out of control.”

Lara acknowledges there are no guarantees. But he notes that the federal government has previously granted waivers to states when they amended or added programs to their healthcare systems — even states that expanded their Medicaid programs, as California did under the Affordable Care Act. California has several past and ongoing waivers, approved under both Democratic and Republican administrations.

Washington’s inclinations and the need for more bill details notwithstanding, state lawmakers have political incentives to pass SB 562. The influential nurses union, for example, has threatened to campaign in the next election against those who vote no.

Still, many who are following the issue say they don’t expect the bill to be signed into law. Gov. Jerry Brown, California’s fiscally prudent chief executive, has expressed concern about the cost.

Proponents say that if the measure does fail in the Assembly or at the governor’s desk, they’ll try again, putting the matter before the next governor or on the ballot again.

CALmatters is a non-profit journalism venture dedicated to exploring state policies and  politics. For more stories by Elizabeth Aguilera, go to calmatters.org.