In summary The effort to create a single-payer healthcare system in California appears to be a lost cause in the short term. But advocates are playing a long game, and they have effectively made single payer a front-and-center issue in California’s 2018 elections.

By many measures the rambunctious campaign for a single-payer health care system in California appears to be floundering.

A bill that would replace the existing health care system with a new one run by a single payer—specifically, the state government—and paid for with taxpayer money remains parked in the Assembly, with no sign of moving ahead. An effort by activists to recall Assembly Speaker Anthony Rendon for shelving the bill has gone dormant. And an initiative that would lay the financial groundwork for a future single-payer system has little funding, undercutting its chances to qualify for the ballot.

But even if single payer is a lost cause in the short term, advocates are playing a long game. For now, it may well be less a realistic policy blueprint than an organizing tool.

And by that metric, advocates are making gains.

Riding a wave of enthusiasm from progressive Democrats, supporters of single payer have effectively made it a front-and-center issue in California’s 2018 elections. It’s been discussed in virtually every forum with the candidates running for governor, emerged as a point of contention in some legislative races, and will likely be a rallying cry at the upcoming California Democratic Party convention.

“This issue is not going away,” said Garry South, a Democratic political consultant who has worked with the California Nurses Association, which sponsored the stalled single-payer bill.

“The progressive elements who are supportive of the single-payer concept know that it’s not going to happen now, it’s not going to happen tomorrow. It’s a long-term process and Jerry Brown is gone as of January 2019.”

The governor has not had to stake a position on the bill because it skidded to a stop in the Assembly last summer without reaching his desk.

But state Sen. Toni Atkins, a San Diego Democrat who co-authored Senate Bill 562, said Brown was not receptive. Analyses peg the cost of a statewide single-payer system at between $330 billion and $400 billion—far exceeding the state’s entire budget. That made it an anathema to Brown’s record of prioritizing fiscal stability for state government.

“When the governor saw that we introduced that bill… all he could look at me and do is shake his head and say, ‘$400 billion dollars.’ And I kept trying to say, ‘Can we back up and talk about what you’ve got to do to get (there)?’” Atkins said in an interview.

“He wasn’t letting it go.”

Atkins, who will take over as Senate leader next month, said she’s not giving up on the goal of single-payer but does not expect it to happen this year. “People are polarized on this issue in a way that’s not good for coming together to get it done,” she said.

Led by the nurses association—a labor union that embraces firebrand activism—supporters of single-payer have targeted Rendon after he shelved the bill last summer, saying it lacked critical information on how to pay for a massive overhaul of the healthcare system. They peppered social media with images that not only portrayed the bill fight as a boxing match between Rendon and the nurses, but also depicted a knife labeled “Rendon” back-stabbing the bear symbol of California.

The nurses were not involved in the campaign to recall Rendon, said recall organizer Stephen Elzie, who has since dropped the effort and is now helping Democrat Maria Estrada challenge Rendon’s re-election bid. But the nurses union leapt into the governor’s race as one of the first labor unions to endorse Lt. Gov. Gavin Newsom. Single-payer has emerged as one of few issues on which the Democratic candidates disagree.

Newsom and Delaine Eastin, the former state superintendent of schools, have both said they support the nurses’ single-payer bill. Fellow Democrats Antonio Villaraigosa, former mayor of Los Angeles, and John Chiang, the state treasurer, say they want to expand health care so that everyone is covered, but not necessarily with the single-payer model that would abolish private health insurers and replace them with a government-run system.

A coalition of medical groups is lobbying against the single-payer bill, arguing that it makes more sense to protect and expand the federal Affordable Care Act, which has increased the number of Californians who have health insurance. Some members of the coalition have a history of spending big money to sway California elections. One of them, the doctors association, donated to Newsom before he voiced support for single-payer; it’s not yet clear if they will shift support to another candidate.

Almost two-thirds of Californians like the idea of a statewide single-payer health care system, although enthusiasm drops significantly if it would require raising taxes, according to polling last year by the Public Policy Institute of California. Still, Californians didn’t cite health care as a top priority when asked last month what the Legislature and governor should focus on in 2018.

The Assembly just wrapped up a series of hearings on what it would take to create a health care system that covers all Californians. It exposed many obstacles—in both federal and state law—to swiftly enacting single-payer. For one, the state would need permission from the federal government—and perhaps an act of Congress—to shift billions of dollars from Medi-Cal and Medi-Care into a state-run single-payer plan. For another, if lawmakers raised taxes to fund single-payer, voters would likely have to approve changes to the California Constitution to allow the money to go to health care instead of schools. (That’s the only single-payer initiative trying to qualify for the ballot, and while a Silicon Valley tech consultant is gathering signatures for it, he doesn’t have support from the nurses union or any other well-financed group.)

Assemblyman Jim Wood, a Healdsburg Democrat who chaired the panel, called the single-payer bill “aspirational” and said he’s instead considering legislation that could help more Californians get health care without requiring permission from the federal government. One idea: extending subsidized health plans to adults who are undocumented immigrants.

“I believe we can actually get to single payer, once we go through a lot of study and a lot of work,” Wood said. “But this feels, at times, more like a litmus test.”