Universal healthcare in California remains a legislative proposal, not a working program. Lawmakers have introduced single-payer bills under the “CalCare” banner repeatedly since 2017, including a new version in the 2025–2026 session, but none has passed both chambers. Even if one did, the state would still need voter-approved tax increases, a constitutional amendment, multiple federal waivers, and an act of Congress to change a 1974 federal law before the system could actually operate.
What CalCare Would Actually Do
Under the CalCare proposals, the state government would become the sole payer for nearly all healthcare services in California. Private health insurance would no longer cover services included in the program. Medi-Cal would be folded in, and the state would seek to redirect Medicare and Affordable Care Act dollars into the same consolidated public trust. Eligibility would extend to every California resident regardless of age, income, employment, or immigration status.
At the point of care, you would stop paying premiums, deductibles, and copays. Those costs shift to new taxes. Whether any given household ends up ahead depends entirely on the tax structure, which no bill has finalized.
The benefit package in the most detailed version, Assembly Bill 2200, was broader than most private insurance: hospital and emergency care, primary and preventive care, prescription drugs, mental health and substance abuse treatment, dental, vision and hearing, reproductive and maternity care including abortion and assisted reproduction, gender-affirming care, long-term services and supports, rehabilitation, pediatric care, hospice, dialysis, and medical transportation, all with no cost-sharing.1California Legislative Information. AB-2200 Guaranteed Health Care for All A CalCare board would have authority to add services over time.
The Bills That Have Tried and Failed
California’s single-payer effort has followed a consistent pattern. An ambitious bill gets introduced, generates attention, and stalls over cost.
AB 1400 (2021–2022)
Assembly Bill 1400, carried by Assemblymember Ash Kalra, was the first fully developed CalCare proposal, paired with a constitutional amendment (ACA 11) that spelled out the tax structure. Kalra pulled the bill in January 2022 without a floor vote after concluding he lacked the votes, even in a legislature with a Democratic supermajority.
AB 2200 (2023–2024)
Kalra reintroduced the proposal as AB 2200. The bill would have created CalCare and required the state to seek federal waivers to pull existing federal healthcare dollars into the new system.1California Legislative Information. AB-2200 Guaranteed Health Care for All It was referred to the Assembly Appropriations suspense file in May 2024 and died in committee when the session ended.2California Legislative Information. AB-2200 Guaranteed Health Care for All
SB 770 (2023)
While the full CalCare bills failed, Governor Newsom signed Senate Bill 770 in October 2023. It directs the Secretary of the California Health and Human Services Agency to develop a framework for securing the federal waivers single-payer would require.3California Legislative Information. SB-770 Health Care – Unified Health Care Financing This is preparation for future federal negotiations, not a step toward imminent implementation.
AB 1900 (2025–2026)
Kalra reintroduced the concept again as AB 1900 in the 2025–2026 session with a new strategy: establish the policy framework first and leave the revenue question for the legislature to resolve afterward. Whether separating the “what” from the “how to pay for it” improves the bill’s chances is the open question of this latest attempt.
How It Would Be Paid For
The financing question has killed every CalCare bill. California’s total personal healthcare spending across all payers reached roughly $411 billion in 2020.4Centers for Medicare & Medicaid Services. NHE Fact Sheet Some of that already flows through public programs. The rest comes from employers and individuals through premiums and out-of-pocket costs. Replacing those private payments with tax revenue is where the political math breaks down.
The most detailed financing plan appeared in ACA 11, the constitutional amendment paired with AB 1400. It proposed three main revenue streams: a 2.3% gross receipts tax on annual gross receipts above $2 million for qualifying businesses; a 1.25% payroll tax on all wages for employers with 50 or more employees, plus an additional 1% on each employee’s wages above $49,900; and a personal income tax surtax on a sliding scale starting at 0.5% on taxable income above $149,509 and rising to 2.5% above $2,484,120, with income thresholds adjusted annually for inflation.5California Legislative Information. ACA-11 Constitution of California ACA 11 never advanced alongside AB 1400, so these rates were never tested politically.
Proponents argue that eliminating insurance company profits, cutting administrative overhead, and negotiating drug prices as a single purchaser would offset much of the new tax burden. The state-appointed Healthy California for All Commission analyzed several design scenarios and found that some configurations could reduce total baseline healthcare spending by 2% to 7% in the first year, while others, particularly those expanding long-term care with no cost-sharing, could increase spending by 10% to 15%. Single-payer does not automatically save money. It shifts money. Whether total spending rises or falls depends on policy choices that have not been finalized.
The Barriers Standing in the Way
Passing a bill is only the first step. Four separate barriers stand between a signed CalCare law and an operating program.
A State Constitutional Amendment
New taxes of this magnitude require amending the California Constitution. That means a two-thirds vote in both the Assembly and Senate, followed by majority approval from voters at a statewide election. The governor plays no formal role.
Two existing provisions complicate matters. Proposition 4, passed in 1979 and known as the Gann Limit, caps state and local government spending at 1978–79 levels adjusted for population and inflation.6California Department of Education. Gann Limit – Accounting A single-payer system spending hundreds of billions would blow through that ceiling unless the amendment overrides it. Proposition 98, passed in 1988, guarantees a minimum level of state General Fund spending for K–14 education as a percentage of General Fund revenues. If the state dramatically increases tax revenue to fund CalCare, the Proposition 98 formula could automatically require a matching increase in education spending. Any CalCare amendment would need to address both provisions directly.
Federal Waivers for Existing Programs
California cannot build single-payer with state revenue alone. Hundreds of billions of federal dollars already flow in through Medicare, Medi-Cal, and ACA premium subsidies. Each stream needs separate federal permission to redirect.
Section 1332 of the Affordable Care Act allows states to apply for waivers to repurpose federal premium tax credits and cost-sharing subsidies. California would have to show the U.S. Department of Health and Human Services and the Treasury that its system provides coverage at least as comprehensive and affordable as existing ACA plans, covers at least as many residents, and does not increase the federal deficit.7Centers for Medicare & Medicaid Services. Section 1332 – State Innovation Waivers Medi-Cal’s federal funding would require a separate waiver, likely under Section 1115 of the Social Security Act, which the federal government has broad discretion to grant or deny.
Medicare is the hardest piece. No existing waiver authority clearly allows a state to redirect Medicare funds into a state-run system. AB 2200 directed the CalCare board to seek “all necessary waivers, approvals, and agreements” for federal healthcare payments, but Congress would likely have to create new authority for Medicare integration.1California Legislative Information. AB-2200 Guaranteed Health Care for All The Healthy California for All Commission recommended a “partially-unified” system that initially excludes Medicare, leaving seniors on their existing federal program while others transition to CalCare.
The ERISA Problem
The most underappreciated obstacle is a 1974 federal law unrelated to healthcare policy. The Employee Retirement Income Security Act preempts “any and all State laws” that relate to employer-sponsored benefit plans.8Office of the Law Revision Counsel. 29 USC 1144 – Other Laws Most large employers in California self-fund their health plans, and ERISA effectively prohibits the state from folding those plans into a single-payer system.
Here is the detail most coverage omits: unlike Medicare and Medicaid, ERISA contains no waiver provision. There is no administrative process California can use to request an exemption. The state cannot apply for relief. Congress has to change the law. The Healthy California for All Commission identified three possible fixes: narrowing ERISA’s preemption to a “floor,” eliminating the clause that shields self-funded plans from state regulation, or adding a waiver provision similar to those in the ACA and Medicaid. None has meaningful momentum in Congress.
Without an ERISA fix, California could in theory build a system that covers everyone except employees of large self-funded employers, which would undercut the point of the whole exercise.
What Vermont Showed
California is not the first state to try. Vermont passed single-payer legislation in 2011 creating Green Mountain Care, which Governor Peter Shumlin championed as his signature initiative. After four years of development, Shumlin abandoned the plan in December 2014. The system would have required an 11.5% payroll tax on employers and income taxes on households as high as 9.5%, increasing the state budget by roughly 45%.
Shumlin cited “the limitations of state-based financing, the limitations of federal law, the limitations of our tax capacity, and the sensitivity of our economy.” California has a broader tax base than Vermont, but it also has to transition 39 million people, and its share of self-funded employer plans makes the ERISA barrier much larger.
Where Things Stand Now
The current state of universal healthcare in California is best described as active preparation without imminent implementation. The SB 770 waiver research is underway. AB 1900 is pending in the 2025–2026 session. The state continues to face significant budget pressures, having addressed a $15 billion deficit in 2025–2026.9Legislative Analyst’s Office. The 2026-27 Budget – Californias Fiscal Outlook
For CalCare to actually launch, California would need to pass a bill through both chambers, pass a constitutional amendment by two-thirds in both chambers, win voter approval for that amendment, secure Section 1332 and Medicaid waivers from a cooperative federal administration, and persuade Congress to amend ERISA. Each step is individually hard. Accomplishing all of them in sequence, during a period of persistent budget deficits, is the kind of project that takes a decade or more, if it happens at all.