LOS ANGELES — During the same weekend that California took its first steps toward securing universal health coverage, the state’s top three Democratic Senate candidates emphasized that the issue remains very much a part of the health care debate.

While the issue has stalled at the federal level, the push toward single-payer health care continues to resonate as a campaign issue for Democrats. Advocates of a unified health system have mostly rallied behind “Medicare for All,” a federal effort that would fund medically necessary care for U.S. residents through taxes.

Sen. Bernie Sanders, I-Vt., the chamber’s biggest proponent of Medicare for All, held the last congressional hearing on the policy in May 2022 while serving as Senate Budget chairman. But the hearing did not spark any new momentum for the bill and mostly served as a forum for partisan debate. And while President Joe Biden campaigned for a public option health system, he has resisted supporting Medicare for All.

State-level action, however, has continued.

On Saturday, California Gov. Gavin Newsom, a Democrat, signed SB 770, a law that kick-starts the process to secure a statewide single-payer health system. It’s the first such move by a state.

Universal health care coverage, ensuring no one is left uninsured, could take multiple forms. Under a single-payer system, one entity would be responsible for all costs. Medicare for All refers to a specific federal single-payer plan sought by some Democrats. 

The law directs the secretary of the California Health and Human Services Agency to work with federal partners on a path forward on a unified health financing system. The agency would be required to submit an interim report by January 2025, a federal waiver framework by June 2025 and a final framework for state leaders by November 2025. 

The timeline would pave the way for a final waiver to be submitted for federal approval in 2026. Health and Human Services Secretary Xavier Becerra, a former California representative and state attorney general, has been a longtime proponent of a single-payer health care system.

On Sunday, the front-runners in next year’s highly competitive California U.S. Senate race — Democratic Reps. Barbara Lee, Katie Porter and Adam B. Schiff — rearticulated their support for Medicare for All as their preferred path to federal universal health care during a National Union of Healthcare Workers conference.

But they stopped short of criticizing California’s separate efforts.

Medicare for All “wouldn’t supersede California’s efforts because, frankly, it will likely take the federal government a lot longer than the states,” Schiff said.

“I think it is valuable to have the states be forward laboratories with single-payer, which I strongly support,” he added.

Conference attendees applauded the new California law during Sunday’s forum. The union will officially endorse one of the three candidates Wednesday.

Still, California’s state-led approach has faced some pushback, including from the largest nurses union, which wants a more comprehensive approach and health payer groups that oppose efforts to eliminate private insurance options.

Sandy Reding, president of the California Nurses Association, called the law a “complete betrayal of nurses’ fight for a single-payer health care policy” and criticized Newsom’s decision to sign the bill as “an utter lack of political courage.” California Nurses Association, a division of National Nurses United, represents 100,000 members in California.

Some advocates have split on whether to seek state-based solutions to universal coverage or whether federal action later could interfere with state-led systems moving at a faster pace. 

At least four states have already implemented a public option, which is a more incremental approach to government-run health care than single-payer health that allows residents to opt in to a government-funded health program or continue with their private coverage.

Washington state, Colorado, Minnesota and Nevada have all enacted laws creating modified public options. Unlike the traditional concept of a government-run public option, these three states partnered with private carriers to offer public option-style plans. 

Several other states, including New Mexico and Connecticut, have considered but not passed legislation to enact public options.

“I do not support a public option or an incremental approach. I support Medicare for All, period, and I am disappointed that when I got to Congress and we had the gavel as Democrats and we had the ability to pass Medicare for All and put it on the floor for a vote, we didn’t do it,” Porter said Sunday.

Lee said she introduced one of the earliest single-payer bills in the 1990s while serving in the California Legislature.

“I’m very pleased that the governor has signed this into law. California once again is leading,” said Lee, who said as a member of the House’s Medicare for All Caucus she hopes to set up a sister caucus in the Senate to further move discussions forward.

Both Lee and Schiff said they advocated a public option during negotiations ahead of the passage of the 2010 health care law. While the law does not include a public option, it does give states the ability to seek federal approval through a so-called 1332 waiver to pivot to a single-payer system.

“Now we didn’t get that,” said Schiff, speaking of a federal public option, “but if we had gotten that we would have had a federal single-payer model for years and years. 

“But we need to pass Medicare for All, and as we fight to make that happen, we need to support efforts like in California to advance single-payer.”

Ariel Cohen contributed to this report.