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With the Affordable Care Act facing an uncertain future, could California set up its own universal health care system as an alternative?

State senators Ricardo Lara, D-Bell Gardens, and Toni Atkins, D-San Diego, recently introduced a bill to do just that — the most recent of several failed attempts to set up a single-payer system in California, in which the state covers the costs of health care for anyone who wants it.

At stake for California is $23.4 billion in federal funding.

At least some policy makers and advocates are open to discussing the idea but they think the first priority should be to save what they believe are the most important parts of the Affordable Care Act.

“As week by week goes by and as popular protests mount, it’s becoming clear the life and death consequences of these decisions,” said Anthony Wright, executive director of the consumer advocacy coalition Health Access California. He believes there’s a better chance now than a couple of months ago that parts of the Affordable Care Act may be saved.

Proponents of a single-payer system say it would reduce administrative costs, passing savings on to consumers and that it would encourage preventative care. Opponents say taxes would go up for everyone regardless of how much they use health care and that there would be less choice and less efficiency in a government-run system.

Meanwhile, the ACA is proving harder to dismantle than Republicans had hoped. While President Trump and Republican congress members made repealing the act a major priority, no consensus has yet been reached on what the replacement should be.

According to a Feb. 17 report by the Legislative Analyst’s Office, the Affordable Care Act reduced the number of uninsured California residents from 6 million to 3 million. As of fall 2016, 4.6 million residents (12 percent) statewide obtained health coverage funded by the ACA through either Medi-Cal or through a subsidized plan from Covered California, the health benefits exchange that lets individuals and small businesses with 50 or less employees shop for insurance.

“We can’t afford to lose the federal funding or we’re going to have huge, huge issues,” he said.

The huge Medi-Cal program, financed by a mix of state and federal money, has served the poor in California for decades, including those receiving welfare assistance.

It also has been going through an expansion to serve the young. Overall, it provides services to about 13.4 million people*, or roughly one in every three Californians, according to the Department of Health Services most recent numbers.

At stake for California is $23.4 billion in federal funding. If the Affordable Care Act is repealed, California could lose $18 billion in federal funding for the expanded Medi-Cal program and $5.4 billion in premium subsidies and cost-sharing reductions for Covered California, endangering the exchange’s survival, according to the Legislative Analyst’s Office report.

Though the threat that the ACA could end health coverage for 32 million Americans is real, “it is no way a done deal,” Wright said.

Wright supports universal health care as an ultimate goal but his group’s first focus is the federal fight which is happening right now. Any state proposal like the single-payer plan will take months to formulate and implement.

“California is not an island,” he said. “We are very much dependent on these federal funding streams for large parts of our healthcare system,” he said. “A single-payer system would have to reclaim those funds and would need a federal partner to do that.”

Assembly member Jim Wood, D-Eureka, who is one of the leaders heading up the Assembly’s efforts to study a single-payer system, said he is “laser-focused” now on trying to save what he believes are the most important components of ACA.

“We can’t afford to lose the federal funding or we’re going to have huge, huge issues,” he said.

Woods said the state doesn’t have the money to backfill $23.4 billion. “That’s not a one-time figure, that would be an ongoing challenge for us.”

“Single payer becomes a diversion when the real focus should be on protecting the gains of the Affordable Care Act.” — David Panush

In principle, he does support universal health coverage. “Health care should be a right, not a privilege,” he said. “A system that covers everyone is a healthier system for all of us.”

But Wood said he can’t give much of an opinion about the new Senate proposal since there isn’t much detail. “Historically, there’s a pretty high price tag on this,” he said. “If we’re going to go it alone, I hope we have a strong financing mechanism to do that. Maybe California becomes a leader on this issue.”

David Panush, president of the consulting firm California Health Policy Strategies, said the senate single-payer proposal would have to overcome some hefty barriers to get the needed two-thirds vote of the Legislature for approval of the needed tax increases. He said it will be difficult to unify the legislators and the governor on a financing plan.

“Single payer becomes a diversion when the real focus should be on protecting the gains of the Affordable Care Act,” he said.

L.A. County Supervisor Sheila Kuehl, a former state senator who authored a single-payer system that was approved by the Legislature, then vetoed by then-Gov. Arnold Schwarzenegger a decade ago, said single-payer may have a better shot at acceptance now.

“The time might be better for single-payer because everybody is worried what it might mean if Washington discontinues subsidies for people who get insurance through ACA,” she said.

In her opinion, it would be better for California to move decisively to universal health care coverage than to leave a sizable group of people without any insurance at all in the event of the repeal of the Affordable Care Act.

Sen. Atkins, who co-sponsored the single-payer bill, seems to agree.

“In light of threats to the Affordable Care Act, it’s important that we look at all options to maintain and expand access to health care,” she said in a written statement.

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*Ed’s Note: Corrects 12.5 million to 13.4 million in 9th graf to reflect latest figures from the state.