After nine years of playing defense on Obamacare, Democratic leaders at the state and local level want to go on offense when it comes to health care.

New plans announced by California Gov. Gavin Newsom, Washington Gov. Jay Inslee and New York City Mayor Bill de Blasio this week also demonstrate that ideas short of single-payer could partially address the shortcomings of America’s health care system ― and reach people the Affordable Care Act did not.

Newsom, Inslee and de Blasio all support the implementation of a national, government-run single-payer health care system, but that’s not the focus of this round of policy proposals.



Instead, the two governors are calling for new programs ― and spending ― to shore up the health insurance market for people who find Affordable Care Act exchange policies too expensive. In New York, the mayor is eyeing a local plan to use city money to cover medical expenses for uninsured residents. The California and New York City proposals include assistance for undocumented immigrants, who are ineligible for federal programs like Medicaid and the health insurance exchanges.

Democrats are bullish on health care as an electoral issue after focusing on President Donald Trump’s agenda during the midterm elections last year, during which the party won control of the U.S. House and made gains in state legislatures and governors’ offices around the country. In addition, voters in Idaho, Nebraska and Utah ― three reliably Republican states ― approved ballot initiatives to expand coverage for low-income residents through Medicaid.

Notably, Inslee and de Blasio are potential presidential candidates this cycle, something Newsom has ruled out. Newsom is in his first days as California governor after winning election in November, while Inslee and de Blasio are each in their second terms in office.

Single-payer health care proposals have become mainstream among Democratic officials at all levels of government in the wake of Vermont independent Sen. Bernie Sanders’s 2016 Democratic presidential campaign and electoral wins last year by proponents of the policy who now serve in Congress and state legislatures.

Other Democrats have proposed an expanded government role in providing health coverage and medical care through means such as a public option plan that would compete with private health insurance or proposals to allow consumers to buy into Medicare or Medicaid.

But it’s virtually certain that no major expansions are going to happen in Washington for the next two years because Republicans still control the Senate and the White House. Their agenda has focused for years on scaling back federal and state programs that provide assistance to low- and middle-income families and would lead to millions fewer Americans covered.

At least for now, it’s up to the states ― and cities ― to act.

“Lots of time and energy has been put into taking away health care from tens of millions of people,” de Blasio said Tuesday during a press conference at a Bronx hospital. “What we’re doing here in New York City, we’re getting health care to a lot of people who never had it before. We’re going the opposite direction.”

California, New York and Washington are among the states that embraced the Affordable Care Act by immediately adopting its Medicaid expansion for low-income adults and by creating state-run health insurance exchanges.

These states also already have relatively generous health care safety nets. The uninsured rates in all three states are below the national average of 10 percent as of 2017, the most recent year for which Census data on the uninsured at the state level are available.

“We have done fantastic things in the state, with one of ― if not the ― most successful health care efforts in the United States,” Inslee said at Tuesday press conference, just hours after de Blasio’s. “But there is more to do.”

Jae C. Hong/Associated Press California Gov. Gavin Newsom﻿ (D) is pushing for policies to expand health care access in his state.

The California Plan

Single-payer is still the main topic of political discussion in California, and among the moves Newsom made on Monday was to send a letter to the Trump administration and congressional leaders calling for legislation that would give states like his the authority to craft their own single-payer systems.

But given that single-payer is staunchly opposed by Republicans in Washington and has struggled to get sufficient support even in California’s Democratic-controlled legislature, the more consequential action, for now, will likely be on three other parts of Newsom’s announcement.

One is a call to substantially increase the financial assistance available to people who buy private insurance through Covered California, which is the online insurance marketplace that the state runs as part of the Affordable Care Act.

Under the Affordable Care Act, tax credits are available to people whose incomes are up to four times the poverty line, or $48,500 for an individual and $100,400 a year for a family of four. People with higher incomes can find coverage difficult, if not impossible, to afford ― even in California, where the marketplace is considered among the most successful in the country.

And because the tax credits are available on a sliding scale, relative to income, even some people eligible for assistance struggle with either premiums, high out-of-pocket costs or both.

Newsom is calling for legislation that would make many more people eligible for assistance ― increasing the thresholds all the way up to $72,840 for individuals and $150,600 for a family of four. The legislation would also provide more assistance for people who already qualify.

In order to offset the cost of those new subsidies, Newsom wants to reinstate the financial penalty for people who do not have insurance ― a penalty that was part of the Affordable Care Act until congressional Republicans and Trump eliminated it, effective this year. This would make California the fourth state to adopt an individual mandate with a penalty; Massachusetts, New Jersey and Vermont already have such a policy in law.

Finally, Newsom called for legislation that would open up Medi-Cal, the state’s version of the Medicaid program, to undocumented young adults. California already offers Medi-Cal to undocumented immigrants until they turn 19. This would push the eligibility age up to 26.

A similar proposal that the state legislature considered last year would have cost an estimated $250 million per year, according to the Los Angeles Times, and it would all have to come from California because federal dollars cannot be spent on health care programs for undocumented immigrants under the Affordable Care Act and other laws.

The outlook for any of these proposals in the state legislature is unclear. California has a history of aggressive action to help people get health care, up to and including its implementation of the Affordable Care Act. But some of its more ambitious initiatives have failed because legislators could not agree on funding and the state constitution requires a two-thirds vote for new taxes.

The other initiative Newsom announced Monday will affect prescription drugs and won’t require legislative action because Newsom was able to use executive authority. He issued an order that will allow one state agency to negotiate prices for all state programs that purchase drugs. That includes Medi-Cal, which by itself insures some 13 million people.

Whether it succeeds in reducing drug prices meaningfully ultimately will depend on a number of factors, not least among them the ability ― and willingness ― of state negotiators to exclude popular but duplicative drugs from coverage because manufacturers won’t agree to lower prices.

Ted S. Warren/Associated Press Washington Gov. Jay Inslee (D) called for a "public option" in his state.

The Washington State Plan

Inslee’s plan is the most straightforward and most familiar, because he wants the state legislature to create something that progressives have wanted as part of the Affordable Care Act all along. He’s calling for the state to create a “public option” ― a stand-alone insurance plan, which a state agency would manage, available to people buying coverage on their own through the state’s exchange, Washington Healthplanfinder.

At the Tuesday press conference, Inslee said the plan would be available in all parts of the state, in part to fulfill one of its chief goals: to make sure everybody has coverage available. Washington, like many states, has had trouble keeping insurers from abandoning rural areas. This year, 14 counties in the state have only one carrier.

The public option would reimburse doctors, hospitals and other providers of health care at the rate that the federal Medicare program uses, Inslee said.

That is no minor thing. Medicare pays far less than commercial insurers and hospitals say the reimbursements are not sufficient to cover their costs. It’s why a public option could potentially offer lower premiums but also why, historically, proposals have generated such intense opposition from hospitals.

In his remarks, Inslee talked about the Washingtonians who were grateful for the coverage they’d gotten from the Affordable Care Act over the last few years ― and those who were still struggling, even with the law fully in place.

“We still have thousands of people in the state of Washington who still do not have that comfort, who still live under the anxiety of a potential loss of coverage, who still are dealing not only with the problem of a disease but the problem of anxiety over their economic circumstances,” Inslee said.

Drew Angerer/Getty Images New York Mayor Bill de Blasio (D) said his plan would be available to the 600,000 city residents who currently are uninsured.

The New York City Plan

The goal of the New York City plan is to promise access to health coverage and health care services to all of the city’s 8.6 million residents, de Blasio said.

“From this moment on, in New York City, everyone is guaranteed the right to health care,” de Blasio said.

According to the mayor, 600,000 New Yorkers who currently are uninsured would be eligible for existing programs he wants to expand and for a new medical care program. Based on that figure, the uninsured rate in New York City is about 7 percent, the same as New York state and lower than the national rate of 10 percent as of 2017, according to Census data.

Medical services for this population will cost the city about $100 million a year once his plan is fully implemented over the next two years, de Blasio said.

About half of those newly eligible people are undocumented immigrants, de Blasio said. The remaining uninsured generally are people who don’t qualify for Medicaid or other city, state and federal programs, including New York State of Health, the insurance exchange. The new initiatives will target young adults in particular, he said.

The plan has two parts. The first is an expansion and enhanced enrollment outreach for MetroPlus, a city-run insurance program. The second is the creation of what de Blasio called NYC Care, which would give uninsured residents ― especially undocumented immigrants ― access to medical and mental health care services provided by hospitals and clinics managed by a city agency.

Patients would pay for care on a sliding scale based on their income, he said. These programs would build on New York City’s and New York state’s health care safety net, which is more comprehensive than in most states.

De Blasio reiterated his support for single-payer health care, both at the national level and in New York state.

The majority-Democratic New York Assembly passed single-payer health care bills several times in recent years, but the state Senate ― then controlled by Republicans ― didn’t take up the measure. Democrats now have a majority in both chambers of the legislature and are set to reconsider single-payer, although Gov. Andrew Cuomo (D) has expressed skepticism.

New York wouldn’t be the first municipality to carry out a plan seeking universal coverage. San Francisco enacted a similar plan in 2007, while Newsom was mayor, and one of that plan’s architects now is a de Blasio adviser. Los Angeles County, California, and the District of Columbia also have local programs that provide coverage and services to uninsured residents that predate the Affordable Care Act.