Single payer, many lawsuits

The idea of single-payer health care in California seems to swing from popular to toxic -- but it never quite goes away.

Now it's back, thanks to surging health care premiums and the most wide-open governor's race in a generation.

Plenty of European countries have single payer systems. But Italy, the U.K. and Sweden don't have an often-hostile federal government, a complex web of Medicare dollars and Affordable Care Act subsidies, and, perhaps most of all, a half-century-old law called ERISA.

Several single-payer bills have died before reaching Gov. Gavin Newsom's desk in recent years. Meanwhile, after the legislative obstacle course comes the legal one.

The next day: Lawsuits

If a California governor were to sign a bill approving a single-payer system, the lawsuits could start piling up within hours -- from insurers, doctors, the federal government, other states, business groups and others.

The state would also need federal waivers like the ones Democratic and Republican administrations have been granting and yanking away for years over California's clean air policies.

"We really have a very fragmented health care system including across both the states and the federal government," said Katie Keith, founding director of the Center for Health Policy and the Law at the O'Neill Institute at Georgetown Law.

Keith added that the kind of litigation would "depend very heavily on the specific proposal."

Experts say the biggest legal hurdle wouldn't be California's right to put a system in place, but its ability to corral the money to make it happen. Michael G. Colantuono, an appellate attorney and expert on public financing rules, said states have a huge role in health care, especially in regulating insurers.

"The federal government's influence comes from its regulation of medical devices and drugs and its control over the federal payment systems," said Colantuono, a partner with Colantuono, Highsmith & Whatley, PC in Grass Valley. "If California were to mandate that insurance companies become intermediaries for a state payer, I think it would be within its rights to do so."

"The hardest part is to bring all of the current funding streams together into one that is state managed," said Elizabeth Y. McCuskey, a professor of health law policy and management at the Boston University schools of law and public health. "Each of the funding streams right now has their own rules and their own managers."

Beige mountain care

"It really depends on what you mean by single payer," said Nicole Huberfeld, a professor who also holds appointments at the Boston University schools of law and public health.

Huberfeld said the "loosely" used term can refer to anything on a spectrum from "Vermont style" to "Massachusetts style."

In 2011, Vermont made an ambitious bid to create something like a European system: Green Mountain Care.

Liberty Mutual Insurance Co. challenged Vermont's requirement that self-insured employer plans report claims data to the state's claims database. That helped convince the governor to ditch the plan in 2014.

Two years later, the U.S. Supreme Court ruled Vermont's reporting requirement violated the often formidable Employee Retirement Income Security Act of 1974, or ERISA. Gobeille v. Liberty Mutual Insurance Co., 577 U.S. 312 (2016), has been seen as a major impediment to single payer ever since.

The court blocked Vermont from even demanding data from insurers -- a far more modest intervention than what would be needed for a single-payer system. ERISA could also make it difficult to impose mandates on employers who operate in multiple states.

Meanwhile, Huberfeld said, Massachusetts has "cobbled together" a system of near-universal coverage, largely under a 2006 law signed by Republican Gov. Mitt Romney.

California has taken many of the same steps. For instance, both states currently hold Section 1115 demonstration waivers from the federal government that allow them to use Medicaid and the Children's Health Insurance Program to expand coverage.

Last week, the California Department of Health Care Services applied to renew its waiver, which is set to expire at the end of the year. But the Trump administration is widely expected to demand California narrow eligibility before giving approval, which could also lead to litigation.

Colantuono agreed that a Massachusetts-style system is the most plausible goal.

"I don't think the state could control how federal dollars are spent without Uncle Sam's permission, which might not be coming before 2028," he said.

One battle after another

Keith said states around the country are trying to find new ways to move closer to universal coverage. She pointed to Maryland, which has embarked on an ambitious plan to expand coverage.

Part of that effort involves controlling costs, something California is also trying to do. Keith said she is tracking a case challenging the state's targets for hospital costs, claiming they are arbitrary and seek to enforce revenue limits. The case grew out of a 2022 state law, SB 184: California Hospital Association v. Office of Health Care Affordability, CPF-25-519370 (S.F. Super. Ct., filed Oct. 15, 2025).

Litigation is a "certainty," Keith said.

"We see litigation over things that I wouldn't expect to be as controversial as something like single payer," she said. "So yeah, I think it'd be safe to assume that there would probably be some legal challenges."

McCuskey said California has something Vermont and other states don't: the world's fourth-largest economy. That could make it easier to make the numbers work, even without some of the usual funding streams.

"State single payer is a real thing," McCuskey said. "I think it is more real in California, not just politically, but because of California's gigantic economy."