As Hillary Clinton’s delegate count creeps towards a hard fought win, Bernie Sanders’ campaign has increasingly hung their hopes on one state alone – California. It might seem like a curious choice. Racially diverse and a part of the Democrats “blue wall,” California seems more comparable to Illinois, New York, or Pennsylvania – all states Hillary Clinton won. Sanders’ support has largely come from more predominantly White states, both within and outside of typical “blue states” with his wins admittedly coming from places as socially different as Oregon and West Virginia.
In spite of breaking the pattern so far, there’s a certain logic to it, particularly if Sanders returned to the rhetoric he used when first launching his campaign. California was initially touted by many as a success story for the implementation of Obamacare, but the longer term frustrations with putting it in place have created an untapped political market in the state that could be decisive if addressed well.
Like all states, California’s experience with Obama-era health care reform boils down to effectively three big picture changes:
- Health care providers and health insurance companies face greater obligations to their patients and customers, but in exchange those customers are required to have coverage.
- In order to help people who would have trouble paying for that coverage, medicaid and other assistance programs are given greater resources and more people are deemed to qualify for their assistance.
- In order to make accessing and assessing insurance plans easier for everyone who can pay for that coverage, those plans will be helpfully listed on online-accessible exchanges.
That seems simple enough, right? At first, California avoided most of the pitfalls and hangups that other states experienced with putting together those initiatives – the state didn’t drag its feet to expand Medi-Cal or leave it to the federal government to build the online exchange’s website. The system worked. The public health care available was enough of a carrot and the threat of a tax penalty for lacking coverage was enough of a stick, and so in 2014’s open enrollment alone 1.9 million people applied for coverage through Medi-Cal and 1.3 million people purchased insurance through the exchanges.
Hopefully you noticed the discrepancy there. People too poor to afford insurance asked the state to provide it for them, and waited a decision. People with enough wealth to buy it bought and had it, end of story. This wasn’t an abstract demonstration of class inequality. This was about access to health insurance, at times to cover chronic or vital health problems. People died from lack of care while the wait list ballooned into the thousands.
Worse yet, the exchanges and Medi-Cal application system – although tied together into one system – would permit people to apply for Medi-Cal, and only that program, if they met the income standards to do so (see answer 9). Lower income people were literally obligated to wait, and denied access to expensive care in the name of protecting them from the cost. Meanwhile, the question of whether they would be liable under the tax penalties for lacking coverage while waiting for an answer from the state remained hanging in the air.
For all its horrifying flaws, with court rulings and administrative decisions this privatized public health insurance model has seen some improvement. Many Californians do, at the end of the day, want to retain the Covered California system, but there is a sizable chunk of the electorate that could stand to hear some talk about how to shake up the system for the better. Looking at the numbers of applicants and enrolled, as a raw number it’s probably a bigger one that is open to criticism of it, even while wanting the system to exist in some form. That’s a tricky place to articulate, where we need this public system but with different ideas underpinning it, but whoever describes it first could become surprisingly popular in California.
Bernie Sanders seemed prepared to be that candidate and speak in that way towards the beginning of the primary campaign. His messages on how he envisions health care policy still speak to many of the fundamental problems a “success story” like California has seen under Obamacare. Health care, under the PPACA, has not become an essential human right that the state must guarantee, but only a public good it will guarantee you if you demonstrate adequate need. The practical application of that – that by the thousands people have to wait for that assessment to occur – is a nightmarish reversal of any talk about inalienable rights, which the Sanders campaign continues to use. In short, the implication in some of Sanders’ statements, that he would reduce or even dismantle the application process for publically-provided health care, taps into the precise flaws and frustrations with the system as is in a place like California.
But, as of now, those have stayed just implications. To be frank, it’s unclear how much any president can or would be able to shape a redesigned ACA that would address that problem. Sanders might actually have a greater ability to champion that within the legislature, and to the extent that he has, could rely on replaying clips of that in a last minute ad blitz in California. He has less than a fortnight for that now. Can he pivot back to that discussion and articulate this nuanced point about a flaw within a means-tested public health care system? It might already be too little and too late.
The featured image for this article is of the California State Senate Chamber in Sacramento, California.