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Single-payer health care didn’t stand a chance in California this year.  Democratic lawmakers shied away from legislation that would have put state government in charge of health care and taxed Californians heavily to do so – a massive transformation that would have forced them to take on the powerful health care industry.

Gov. Gavin Newsom, who had promised to spearhead single-payer when he ran for governor four years ago, dashed its chances this year when he declined to publicly support it.

Instead he is pushing for “universal health care,” which aims to provide all Californians with coverage but, unlike single-payer, would keep private health insurance intact.

And according to a report by the death of single-payer in the nation’s most populous state also deals a major blow to similar campaigns elsewhere in the nation – which had looked to California for inspiration and leadership – casting doubt on their ability to succeed.

We’re also fighting in New York, but just like in California, there’s not 100% Democratic consensus among legislators,” said Ursula Rozum, co-director of the Campaign for New York Health, which is working to pass single-payer legislation. “It feels like a constant question of ‘Can we win this?’”

Health policy experts agree that California’s failure to adopt single-payer dampens momentum across the country.

“California, given its size and politics, has always been a bellwether for progressive policy, so this certainly sends a signal to other states about how hard this is,” said Larry Levitt, executive vice president for health policy at KFF.

But Rozum and single-payer activists in Colorado, Washington state, and elsewhere say that rather than giving up, they are taking key lessons from California’s failure: It is essential to win – and keep – support from the governor. Groups pushing single-payer must unite Democrats, bringing in business-friendly moderates and broader support from organized labor. And they say they must learn how to counter intense lobbying by doctors, hospitals, and health insurance companies fighting to preserve the status quo.

So far, single-payer proponents haven’t been able to broaden their movement beyond liberal activists or convince people that they should pay higher taxes in exchange for scrapping health care premiums, deductibles, and copays.

The only state that has passed single-payer, Vermont, didn’t implement it.  Vermont adopted a single-payer plan in 2011 with unequivocal support from its then-governor, Democrat Peter Shumlin. But he abandoned the effort in 2014 amid growing concerns about tax increases and runaway health care costs.

But progressive dreams for single-payer didn’t die when Vermont retreated. “Medicare for All” became a liberal rallying cry for Democrats nationally when Vermont Sen. Bernie Sanders stumped for it during his presidential campaigns. After President Joe Biden was elected, the movement shifted to the states, in part because Biden has opposed Medicare for All.

Activists in Colorado are mobilizing for another single-payer campaign after the overwhelming defeat of a 2016 ballot initiative that failed partly because of intense health care industry opposition. Organizers in Washington state are pushing legislation and trying to get a single-payer initiative on the ballot next year.