Creating a California public insurance option
Under this approach, the government could compete with private insurers in the health care marketplace and offer more coverage choices in regions with few current options or high-priced plans.
The idea is attractive to policymakers like Assemblyman Jim Wood, D-Healdsburg, who represents a large swath of the North Coast, extending from Santa Rosa north to the Oregon border.
"As someone who represents a very rural district, there is appeal to this for me personally," he said. "We have less competition in the health care plans that are available out there, so why not have this as an option? For people (who) simply don't have a lot of choices, this could be an amazingly positive opportunity for them."
One idea would add a government-run public option to the current plans offered through Covered California. Another approach would build on Medi-Cal, expanding it to create a competitive alternative to existing plans.
Expanding state financial assistance to purchase insurance
State Sen. Ed Hernandez, D-Azusa, has introduced Senate Bill 1255 to expand existing federal subsidies with state money to help consumers purchase insurance on Covered California.
A report released this week to the Assembly's special health committee, charged with identifying a path to universal coverage in California, also recommended lawmakers make Obamacare more affordable by boosting financial assistance with state dollars.
Hernandez is eying $900 million that was set aside for the Children's Health Insurance Program if the federal government had defunded it. But that never happened.
"I'm hoping that money can help reduce the cost of health insurance through Covered California," Hernandez said.
California Department of Finance spokesman H.D. Palmer warned, however, that the state could be on the hook for future cost increases for new programs, such as the idea Hernandez is suggesting. Federal funding for the children's health program is expected to decline in future budget years, "which means, by definition, the state share would have to increase over time."
Covering undocumented immigrants
At present, the vast majority of Californians – 93 percent – have some type of coverage. There are roughly 3 million remaining uninsured residents. Nearly 2 million of them are undocumented immigrants, who are not covered by Obamacare. Many have incomes that would enable them to qualify for Medi-Cal.
State Sen. Ricardo Lara, D-Bell Gardens, previously led the state's efforts to expand Medi-Cal to kids. Now he wants to do the same for undocumented immigrants ages 19 and older who don't currently qualify for the program.
He's tried it before – four times – unsuccessfully. This year he's proposing it again with Senate Bill 974, which could go far in reducing the ranks of California's uninsured. Gov. Jerry Brown has not been receptive.
"The governor never had animosity toward the population we're trying to serve ... it was trying to get to the real cost," Lara said. "I think this is a perfect year for us to make this happen."
Imposing a California individual mandate
President Donald Trump, backed by Republicans in Washington, has formally ended the individual mandate under Obamacare that requires citizens to have health coverage or pay a federal tax penalty. That requirement expires in 2019.
As a result, health insurers and policy experts are concerned healthy, young people will drop their health insurance, destabilizing markets and making coverage even more expensive.
No lawmaker has formally endorsed an individual mandate bill, but some are considering it. The California Association of Health Plans backs the idea.
"We are greatly concerned about the impact the federal repeal will have on premiums for people purchasing their own coverage, combined with the hundreds of thousands of Californians who wold choose not to purchase coverage without a mandate in place," said Charles Bacchi, president and CEO for the California Association of Health Plans.
"We are talking to policymakers about the need to introduce legislation this year that would establish a state-based individual mandate ... as a way to stabilize California's health care market and protect Californians from facing even higher health care premiums."
Controlling rising health care costs
The high cost of health care was ranked as Americans' top financial concern in a Gallup poll last year. Coverage is expected to get more expensive, with nationwide costs expected to rise 5.5 percent every year between now and 2026 and Obamacare premiums in California projected to increase 35 percent by 2021, according to Covered California.
Former Vermont Gov. Peter Shumlin has recommended California lawmakers control rising health care costs by changing the way providers are paid, from a system based on volume of services to one that rewards better health outcomes.
Rising health care costs are being driven largely by unregulated prices in the commercial market, where most Californians get their health care, but also by hospital consolidations. As chains have grown bigger, health insurers and and plans have also consolidated, arming them with more purchasing power to negotiate lower prices.
But patients aren't always on the winning end of that.
"They may get lower prices, but they don't necessarily pass those on to consumers," said Larry Levitt, a health economist and co-executive director for the Program for the Study of Health Reform and Private Insurance at the Kaiser Family Foundation.
Wood wants to bring some regulatory oversight to health plan mergers, which could help drive down prices. He has proposed Assembly Bill 595, which would give state health insurance regulators the chance to deny mergers and allow the public to weigh in.
Other efforts are underway to control costs by lowering prescription drug prices, capping payment rates to medical providers and requiring health plans to limit the amount of revenue spent on profits, marketing and administrative costs, requiring them instead to spend that money on patient care.
Additional bills already in print include one that would seek to ban Medi-Cal work requirements being spearheaded by the Trump administration. Another would prevent insurance companies in California from selling bare-bones plans or charging higher premiums for people with pre-existing conditions.
Path to single-payer
A Commonwealth Fund survey this year shows growing support for a universal health care system, among both Republicans and Democrats. A poll this month found that 92 percent of adults believe all Americans should "have the right to affordable health care" – 99 percent of Democrats said so, followed by 92 percent of independents and 82 percent of Republicans.
Assemblywoman Laura Friedman, D-Glendale, is outlining an alternative route for California to achieve single-payer. She is considering a possible bill that would set the state on a course to implement a taxpayer-financed universal system after certain benchmarks are met, such as reining in health care costs and securing federal waivers needed.
"For those of us who believe in single-payer, the question is how do we get there," Friedman said. "We want to take meaningful steps toward single-payer and at the same time, improve our current system. Not everyone has the luxury of waiting a couple of years, but there's no reason we can't be ready when we have a new (federal) administration."
Lt. Gov. Gavin Newsom, a proponent of single-payer, said the proposals under discussion are "a step in the right direction, with the potential to move California closer to our ultimate goal – a system of universal, guaranteed single-payer health care."
"Californians want action now, and we can't afford to wait for the next election or federal permission to start laying the groundwork," Newsom said in a statement. "With a short-term focus on increasing access while reducing costs, we can build an onramp to universal access through single-payer – and I'm open to any ideas that will get us there."