Why I Voted No on the Healthy California for All Commission Final Report

By Carmen Comsti

Commissioner Comsti speaking at the final Healthy California for All Commission meeting on April 25, 2022.

Back in December of 2019 I was honored to be appointed by Governor Gavin Newsom to the newly created Healthy California for All Commission. The purpose of the Commission was to develop a plan for universal health care in California “through a unified financing system, including, but not limited to a single payer financing system,” and to deliver a report with its findings by 2021.

Ultimately, I felt that the Commission did not fulfill our stated goal when our final report was delivered this April. I want to fill you in on my sense of what happened, and why I ultimately voted no.

As the lead regulatory policy specialist for the California Nurses Association / National Nurses United (CNA/NNU) — proudly working on health care policy and legislation for the largest union of registered nurses in the country — I was eager to put my expertise to use and bring us closer to guaranteed health care as a human right for every California resident.

Through my work at CNA/NNU, I have seen how harmful and deceitful the profit-driven health care industry can be, both at the facility level where our nurses sometimes have to go on strike for patient safety and in politics. I’ve seen hugely profitable hospital corporations force nurses to work in unsafe conditions without optimal protections or safe staffing — the same corporations that are currently pursuing dangerous “home all alone” practices that replace 24/7 hands-on nursing care with remote technology. And I’ve seen giant corporations like CVS Health (owner of the health insurer Aetna) contribute millions of dollars to block Medicare for All.

Contrary to the worsening trends of corporate health care, I saw my role on the Commission as an important opportunity to help lead the largest state in the country (and fifth largest economy in the world) to a more humane health care system, where everyone can get the health care they need without regard to their ability to pay. And without a doubt, based on countless studies and the real-world examples of many other countries, I knew that the most effective and efficient way to do this is through a single payer health care system, like CalCare and Medicare for All.

Unfortunately, getting wins from this Commission was a somewhat uphill battle. Including myself, there were only a few members of the 18-member commission who were consistently vocal and unequivocal in our support for a true single payer system. There were also a few more allies who generally supported single payer, but respectfully, too many of the other commissioners were tied to the status quo and supported a plan for managed care type organizations and other risk-bearing entities (aka insurers).

However, despite the gaps in the Commission’s final report, we made some serious strides collectively as a movement. Over the course of the Commission process, spanning over 2 years and 15 meetings, we genuinely addressed all the repeated bad faith policy questions and concerns that politicos raise about single payer.

I can say that we built the most policy-educated single payer movement that we’ve had so far in California. Health care justice activists packed the meetings every month, made insightful policy comments, and showed our elected leaders that we were serious about the merits of single payer.

The timing of the Commission was actually fortuitous as we were pushing the CalCare bill (AB 1400) through the Assembly committees earlier this year. With the lack of in-person hearing opportunities due to the pandemic and the presence of two key legislators as non-voting members of the Commission, the Commission meetings became a platform to advocate for AB 1400 and demonstrate the strength of our movement. And I believe that all of our engagement with the Commission helped move Assembly Health Committee Chair Jim Wood to support AB 1400.

In terms of our effect on the Commission process itself, I can point to the following wins:

  • We secured additional meetings, including a September 2021 meeting on racial equity that was not originally scheduled to happen.
  • We heard from prominent policy and political experts who reaffirmed the advantages of single payer. Commissioner Bill Hsaio talked about some of the strengths of the single payer system he helped shape in Taiwan. Former Vermont Governor Peter Shumlin said California can absolutely lead the way in doing single payer.
  • UC Berkeley Labor Center’s Ken Jacobs gave another authoritative voice on what we already know from multiple studies: that single payer would be more fiscally sustainable than our current system, and that there are a myriad of ways to progressively finance such a system.
  • The community engagement process conducted by the various health foundations on behalf of the Commission showed that an overwhelming majority of low-income Californians both strongly support “a single, statewide, government-run health care program that covers all people who live in California” — in other words a single payer system — and strongly support replacing premiums, copays, and deductibles with progressive taxation to get there. And support among Californians of color for single payer is higher than support in the aggregate.
  • The Commission’s own consultants did a cost analysis showing that under a single payer system, we can offer full coverage that includes community and institutional long term services and supports, with no cost sharing, while still saving money over our current system in the longer term. In fact, it would only take three years for such a system to start reaping savings.
  • The legal memo on federal health program waivers and appendix on Employee Retirement Income Security Act (ERISA) show that there is a potential path to single payer open without Congress passing new legislation. We have an opportunity to move forward on single payer now, and California should step up to the challenge.
Slide from the Community Engagement Webinar Presentation on September 21, 2021.

Despite these victories, the steps outlined in the final report to get to single payer are muddy. The Commission could have done a significantly better job to highlight and detail a clear path to achieving single payer. Instead, the report presents no clear recommendations on single payer. I strongly believe that the Commission has not met the obligations it was given by the Governor and legislature.

More specifically:

  1. The Commission has not adequately analyzed a plan for achieving single payer, as required by our enabling statute. At best, the Commission has buried the lede on the benefits of single payer.
  2. There are clear short-comings and potential problems with the so-called intermediary health plan option that were not adequately discussed in the report.
  3. The Commission’s report confuses reforms of our system as prerequisites to single payer. Let’s not create more steps than necessary on the road to single payer. Some reforms can be done at the same time as we move to single payer, and others may be more effective after we have a single payer system in place. And other reforms may be obsolete and unnecessary after implementing a single payer system.
  4. There is a clear need for the legislature to pursue a bill to enact single payer, and the Commission should have made clear recommendations to the legislature. The first formal step in moving California to implement single payer is to pass a policy bill. Everything else follows. Federal waivers follow. Finalizing a financing plan follows. We must pass policy legislation first. Informal discussions with the federal government are insufficient to enact single payer in California.

For all these reasons, I could not agree that we met our charge as a Commission, and therefore I voted No on transmitting the final report. The final report falls short of its stated goal to move us down the path toward a single payer system.

Amidst a global pandemic and the increasing right wing attacks on reproductive rights, gender-affirming rights, and LBGTQ+ rights across the country, it’s more important than ever for California to put forward strong legislation to guarantee health care as a human right. Now is the time.

I am still hopeful, and I know that we can continue to build a health care justice movement that is powerful enough to win. I want to thank all of the CalCare supporters for having my back throughout this process.

It’s been frustrating at times to feel like I was one of the few voices of reason, demanding California act with courage and fortitude to end our inhumane profit-driven system of insurance, on this Commission. But having supporters like you in my corner made this process much more tolerable. Even with the best policy arguments, we will only win by building our power together as a movement. And I will continue to be by your side, fighting every day, until we win single payer in California.

I look forward to a new CalCare bill being introduced in 2023. Onward to victory!

Click here to view Commissioner Comsti’s 2 page comments on the final report. Click here to watch CNA’s last CalCare prep meeting for the final commission meeting.

Video of Commissioner Comsti speaking at the final commission meeting on April 25, 2022.

Transcript: Carmen Comsti’s Remarks at Final Commission Meeting

Commissioner Comsti was the sole NO vote on transmitting the final report to the governor and legislature. This transcript has been lightly edited for readability.

I want to first thank you Secretary Ghaly and my fellow commissioners. We knew when we started our work as a commission that if we did not fundamentally change our fragmented health care system — it’s a system that allows profit-driven insurers and profit-taking healthcare corporations to thrive at the expense of Californians — that we would pay the price with our health and with our lives. And our work as a commission needed to be done with clarity, conviction, and with the utmost urgency.

I have proudly represented frontline nurses throughout this commission and the pandemic — nurses who dedicate their lives and far too many of whom have paid with their lives to care for Californians and people across the country. And I have seen that I owe it to them to push and help our state to meet nurses’ consistent demand for decades that health care be recognized as right for all regardless of ability to pay, without being tied to a job or immigration status, and regardless of whether an insurance company deems us to be a liability to corporate pocket books.

And of course I know that not everyone on the commission has had the same perspective as me and I know that we have disagreements on the details, but I am a steadfast supporter single payer and I felt it it has been my duty to ensure that we fulfill that part of our legislative charge to develop and present a clear plan for achieving single payer in California.

In our final report, the analytic findings confirmed numerous previous studies on single payer systems that it would save patients and government money and that it can do so while providing comprehensive benefits to all. And the report’s appendices on federal waivers and ERISA confirm that there are legally reasonable paths that we can take and test on unified financing and single payer. And of course, like everybody else has said, the community engagement report confirmed that low-income Californians overwhelmingly support a single government-run health care system and they support replacing premiums, co-pays, deductibles with progressive taxation to get us there.

And while our report highlights many of these things that we already know about single payer, the steps to get there, as others have described, are muddy at best. I think the report falls short of presenting clear, concrete, formal (not informal) actions to get us to single payer. And I think the simplest way to describe it for me is that we bury the lead on single payer and its benefits. The report scarcely uses the phrase “single payer” at all and instead we do this implicit reference to it through the direct payments model. And without listening to the dozens of hours of very robust conversations among all of us, you might not know from the final report that single payer was even ever discussed fully in commission meetings.

I recognize that a lot of people made a lot of contributions from the draft of the report and that there are improvements, but at the end of the day the commission’s use of the term unified financing and other key terms — because we lack definitions — has always been opaque. And a major issue with our work is that we never came to a clear understanding of what certain things are, particularly the so-called intermediary option. And like I’ve said multiple times, I continue to underscore that a system that includes a role for health plan intermediaries is not and should not be considered unified financing because fragmentation in the financing would continue.

The report conflates single payer systems with health plan intermediary systems under the umbrella term of unified financing and fundamentally, without clear definitions of single payer / unified financing, we cannot have a clear path for achieving them.

A few more points that I want to highlight: the report confuses some reforms, some of which we didn’t discuss at all, of our current system, as prerequisites to unified financing. Some reforms can be done at the same time. Other reforms may be more effective after we have a single payer system in place, yet others described in the report would be obsolete if we had a single payer system.

I think as a commission we also haven’t given recommendations to the legislature despite discussions about needing legislation to obtain federal waivers.

And of course we did highlight the issue and importance of health equity, but we also didn’t have clear plans for rectifying the ongoing problems with the lack of direct community engagement with low-income Californians, Californians of color, and other underserved communities in the process of redesigning our health care system.

All of this is to say that I see a lot of procedural problems and structural problems in the final report among a lot of other things that I highlighted in my survey comments, and I cannot with full confidence agree that we’ve met our charge as a commission. So I just want to let you all know that I will not be voting to transmit the report, but I am still hopeful that the state of California acts with urgency and takes decisive, effective, formal steps to lead our state and our country to single payer. The final report falls short of providing the necessary ignition that starts us down the road to universal healthcare for all under a single payer system.

I, of course, am truly and deeply appreciative of all of my colleagues on the commission. I absolutely appreciate every conversation that we’ve had, but I also want to recognize and I am truly in awe of the dedication of the members of the public who have stepped up in the past two plus years as a movement to sincerely answer every question and concern about the policy of single payer that has been raised during this commission.

I think together we will keep on fighting to ensure that California acts urgently to transform our profit-driven health care system, our fragmented health insurance system, into a single payer system that prioritizes patient care where everyone is finally in and nobody is out. And with that I want to thank you all again. I deeply appreciate all the work everyone has done and thank you.



Nurses' Campaign for Medicare for All

National Nurses United is the largest union of nurses in the US. NNU is leading the fight for Medicare for All on behalf of our patients and our communities.