Almost every Democrat believes that the United States should catch up with the rest of the world’s democracies and embrace universal, comprehensive affordable health care. There is no clearer example of the failure of private markets than America’s health care crisis. Only government -- as a regulator, funder and service provider -- can get us to the goal. But there is an increasingly vitriolic debate among liberals and progressives on how to get there, and how fast.
The simplest, most affordable and most equitable way to do that is to cover every American with what’s called a “single-payer” system in which the federal government -- or, some believe, state governments -- collects taxes and is the sole provider of all health insurance. It sounds simple, and it has been tested in the U.S. since Medicare was established for every American over 65 years old in 1965.
Health care reformers have made several attempts to reach universal care, however, and they have all failed. A look back at past campaigns for universal health care is instructive and can help ensure that history doesn’t repeat itself.
In 1945, President Harry Truman proposed a universal health insurance program with the federal government as the single payer. At first polls showed that 59 percent of Americans supported the plan, but then the American Medical Association and other health industry lobby groups waged a nationwide propaganda campaign to thwart Truman’s plan. By March 1949 support had fallen to 38 percent, and then to 24 percent by October 1950. It never had a chance to get through Congress.
In 1994, progressive groups, including the California Nurses Association, advocacy organizations like Health Access and other unions put a single-payer measure on the California ballot. Thousands of volunteers collected 1 million signatures in 90 days (a feat that rarely happens in ballot-heavy California) to put what became Proposition 186 before the voters. A coalition of groups believed that Californians were on their side, based on a Gallup poll that claimed that 70 percent of the American people supported a Canadian-style single-payer system. It was an exciting campaign. They held 1,500 house parties around the state and raised $3 million from the grassroots fundraising. They recruited dozens of organizations -- large and small -- to support the campaign.
The insurance, hospital and medical industry lobby predictably opposed the measure and spent about $10 million, a relatively small sum for a California ballot measure, against Prop. 186. They could have raised much more, but they didn’t need to. Californians simply weren’t buying what the single-payer activists were selling, and Prop. 186 got clobbered by a 73 to 27 percent margin.
The organizers (who included one of the authors of this article, Donald Cohen) made some crippling strategic errors. First and foremost, they completely miscalculated the voters’ appetite for a single-payer plan. Their enthusiasm in the heat of the exciting campaign and clarity of the overwhelming superiority and need for a single-payer system clouded our understanding of the political context at the time.
Prop. 186 would have created a well-designed health care system. In terms of expanding insurance coverage and reducing health care costs for Californians, the facts were on its side. Premiums would have declined more than taxes would have increased -- a net benefit for most consumers. But that idea was difficult to convey, especially when the opposition was muddying the message.
It was also a fact that Proposition 186 called for a huge government program with lots of new taxes. This came at a time when American voters -- influenced by a decades-long anti-government propaganda campaign funded by business interests -- were rejecting government action in general and government health care in particular. The Prop. 186 campaign was launched in 1994, just as the health insurance industry was funding an expensive (and ultimately successful) campaign against President Bill Clinton’s much more modest health care reform plan. They sponsored a clever TV ad campaign, featuring an attractive fictional coupled named Harry and Louise, designed to make “big government” control of health care seem like a toxic and terrible idea. It worked.
Prop. 186's organizers might have chosen a more strategic path had they started with a more accurate analysis of public opinion and a clear understanding of the power and reach of the medical-industrial complex. But in all likelihood their single-payer ballot measure would have been doomed to defeat anyway in the political context of hostile public attitudes toward government.
But that hostility did not extend to all of government, and not even to all government health care programs. Prop. 186 was on the ballot in 1994 when Republicans won a surprise majority of the House of Representatives and elected the Rep. Newt Gingrich of Georgia as speaker. His so-called Contract with America policy agenda included a direct assault on Medicare, the government-run health insurance program for senior citizens.
Gingrich’s plan to destroy Medicare went down to defeat. It turns out that most Americans like Medicare. They recognize that it is efficient and effective. They know that it is a government-run program, even if they sometimes get confused about that. (Remember the signs at Tea Party rallies in 2010 demanding “Get the government's hands off my Medicare”?)
It’s become a cliché that Americans don’t like taxes. But that’s not entirely true either. Studies like Vanessa Williamson’s new book, “Read My Lips: Why Americans are Proud to Pay Taxes,” suggest that people don’t mind paying taxes if they think they are getting something for their money. But they don’t like paying taxes when they think it will mostly benefit the undeserving “other” who doesn’t pay taxes, who came to the U.S. illegally or who depends on government “handouts” (and who, not coincidentally, happens to be black or Latino).
Polls show that most Americans think that government is filled with “waste.” But they can’t put their finger on where that waste is. Williamson found that people have different ideas about waste -- most actually refer to programs they don’t like as waste, as opposed to bureaucratic inefficiency. They don’t think that public school classes are too small or that we have too many parks or too many firefighters, or -- at least for the majority -- too many weapons systems. But they know that government “waste” exists and that politicians shouldn’t ask for more of their hard-earned money until they “clean up” the waste.
Most Americans haven’t yet come around to understanding that most big corporations waste a lot more money. For example, private insurance companies spend much more on administrative costs than Medicare or the Veterans Administration.
This gets us back to the current debate over health care reform -- or how to get to universal, comprehensive and affordable insurance for all Americans.
That debate isn’t just about public policy. It is also -- in fact, more fundamentally -- a debate over political strategy.
The battle for universal health care today is, in some ways, déjà vu for the 1994 health care battles in California and nationally. Polls continue to show broad support for universal health care. A recent nationwide poll sponsored by the Associated Press and the NORC Center for Public Affairs Research found that 62 percent of Americans believe it is “the federal government’s responsibility to make sure that all Americans have health care coverage.” A recent Pew Research Center survey found that 33 percent of Americans -- and 52 percent of Democrats -- say that health insurance should be provided through a single national system run by the government -- in effect, "Medicare for all" or single-payer.
This is a strong core of support. But polls only reflect the public’s views at a particular time, and before they are assaulted with TV and radio ads, distorted news stories and other misinformation that challenges their opinions. There are polls that express values and there are polls that stand up to the bare-knuckle battles in the heat of a political campaign.
The 1994 California single-payer campaign wasn’t informed by the latter -- only enthusiasm for the former. That syndrome persists. One health care activist recently predicted “explosive growth of the movement for single-payer health care” as evidence that the public is finally ready. Perhaps, but his enthusiasm sounds remarkably similar to the preconceptions that clouded Prop. 186 supporters’ ability to accurately assess voter attitudes 23 years ago.
There is much that health care reformers should learn from that 1994 battle in California as well as the battle to adopt the Affordable Care Act -- often called Obamacare -- in 2010.
Obamacare won in Congress by a very slim margin. To win enough votes to pass that landmark law, especially in the Senate, President Obama and its supporters had to water down their original plan. Any effort to control drug prices -- a major cause of rising health care costs -- was doomed in the face of opposition by the drug industry lobby. The insurance lobby killed the idea of a “public option” -- a proposal to allow consumers to pick between insurance plans by private corporations and an expanded version of Medicare.
Despite these compromises, Americans like many features of the ACA -- particularly its prohibition against private insurance companies denying coverage to people with “pre-existing” conditions. They also like the ACA’s mandate that all private insurance companies provide a basic standard of insurance coverage that includes regular visits to doctors and nurses, tests and screenings, surgery, and much (though not all) of the cost of medications. They are also pleased with the fact that, thanks to the ACA, an additional 20 million Americans have health insurance compared to before it was adopted in 2010.
What Americans do not like about the ACA is the rising cost of insurance premiums. The fact that premiums have been going up more slowly since Obamacare began -- and that decisions to raise premium prices are made by the for-profit insurance companies -- is little solace.
Despite these complaints about the ACA, what we’ve learned in the past few months is that Americans are much more unhappy with the Republicans’ plans to “repeal and replace” it.
Most Americans realize that Obamacare significantly expanded the number of people with insurance coverage, improving their lives and their economic security. Most Americans continue to dislike and distrust the insurance industry, which they view as putting profits over people.
Single-payer proposals face the same (and worse) hostile political climate concerning government and health care as they did in 1994. The health care industry will spend whatever is necessary to reframe the debate to make it about “big government” and “more taxes.” They will play on Americans’ distrust of government (particularly the federal government), which -- thanks to conservative propaganda and news media cynicism -- is even greater today than it was in 1994.
The Democrats just won a big victory by thwarting the GOP’s repeal effort. Democratic and Republican voters alike opposed the GOP efforts to scale back Medicaid -- a government program for poor people. That's a sign of genuine progress in the larger fight over universal health care.
Americans clearly have an appetite to reform, rather than repeal, the ACA. Polls show they trust the Democrats to do that more than they trust the Republicans. But progressives could blow this opportunity to move the health care ball further down the field.
Republicans have already formulated their talking points to attack Democratic candidates on health care. No matter what Democrats propose in next year’s House and Senate elections, the Republicans will call it “socialism” a “government takeover,” “tax-and-spend liberalism,” and other poll-tested phrases. They will focus on the fact that a European-style single payer plan would, according to the Urban Institute, increase taxes by $32 trillion over ten years. Democrats will respond that those additional taxes will primarily fall on the wealthiest Americans and that for most Americans insurance premiums will decline more than taxes will increase. Their facts are accurate. But facts often get lost in the middle of expensive political battles where the media reports “both sides” as though they were equally true.
The California experience should serve as a lesson to progressives around the country about the next round in the battle over federal health care reform. But right now it appears that, flush from their victory preventing the repeal of Obamacare, Democrats are reassembling their circular firing squad, engaging in a self-destructive public debate over how to move beyond Obamacare to universal comprehensive affordable health care.
On the surface, it is a debate about how, and how fast, to get to a universal health care. But, in reality, it’s really a debate about political strategy.
On the one side are the advocates of a Canadian-style single payer system. Bernie Sanders popularized the single-payer idea during his presidential campaign. The organization he created to carry on, Our Revolution, is now urging Democratic candidates to pick up the single-payer torch and run with it. In fact, they want to make support for single-payer a litmus test for their support. They have even threatened to run candidates in Democratic primaries against congressional incumbents if they refuse to embrace single-payer.
“Any Democrat worth their salt that doesn’t unequivocally say Medicare-for-all is the way to go? To me, there’s something wrong with them,” former Ohio legislator Nina Turner, president of Our Revolution, told Politico. “We’re not going to accept more hemming and hawing. No more game playing. Make your stand.”
The Berniecrats have recently field-tested this idea in California. There, the California Nurses Association (CNA) -- the most fervent Sanders supporters within the labor movement -- proposed creating a statewide single-payer system. They crafted a shell bill that passed the State Senate, but was stopped in its tracks by Assembly Speaker Anthony Rendon, who complained that the bill lacked specifics on regulations and funding mechanisms, and would require the Trump administration and Congress to allow California to divert federal Medicare and Medicaid funds into the state’s single-payer system.
Rendon was also trying to protect a number of Assembly members from swing legislative districts from having to vote on a single-payer bill that might have cost them their seats, and the Democrats their significant majority in the lower house of the state legislature. CNA, which alienated many other progressives and union leaders with its hardball tactics, is now threatening a recall campaign against Rendon.
The battle over single-payer in California also spilled over into the fight over the chairmanship of the state Democratic Party -- with passion on both sides and plenty of vitriol between them. One candidate, Eric Bauman, was an experienced progressive activist and a longtime single-payer advocate. He was opposed by Kimberly Ellis, a political newcomer favored by many Sanders backers. The May convention, with more than 3,000 delegates, was a raucous affair. After Bauman narrowly won the election, Ellis refused to concede. She and her supporters demanded an audit of the vote and accused Bauman’s supporters of rigging the election.
The GOP will certainly keep up the fight to roll back Obamacare, weaken Medicaid and chip away at Medicare. An intra-party war among Democrats could lead to continued GOP control of the House and give them another chance at success, not to mention a chance to roll back other basic protections of civil rights, voting rights, reproductive freedom, climate change, the minimum wage and many other issues, including health care.
Most progressives hope that the Democrats will win a majority of seats in the House in November 2018. They view that as the best way to neutralize Trump. Democrats could hold hearings on the Russia scandal, Trump’s taxes and business activities, and other issues. By controlling one house in Congress, they could thwart Trump’s legislative initiatives.
Next year’s political map makes it almost impossible for Democrats to gain a majority in the Senate. The GOP will be defending just eight seats, while Democrats must fight for 23 — plus another two held by independents (Sanders and Angus King of Maine) who caucus with Democrats. Eleven of the seats they must defend are in states won by Trump. To gain a majority, the Democrats would have to hold on to all 25 of their seats and topple Republicans in at least three states. But the Senate political map is more promising in 2020 when two-thirds of the seats up for election will be held by Republicans (although only two of those are in states carried by Hillary Clinton last November).
Immediately after Trump’s victory, it seemed unlikely that Democrats could regain control of the House of Representatives, where they need to win a net 24 seats to have a majority. In November, Hillary Clinton beat Trump in 23 House districts that were won by Republican candidates for the House. At the time, those 23 seats seemed like the upper limit of potential Democratic shifts. Even if Democratic incumbents held on to all their seats and Democrats won all of those 23 additional seats, they would fall just short of a House majority.
But the number of “swing” districts has grown in the wake of the Trump meltdown. Since January, the Democratic Congressional Campaign Committee has expanded its list from 59 to 79 GOP-held seats it intends to target, hoping to take advantage of Trump’s historically low popularity, the upsurge of activism, and growing local protests against House Republicans.
To win in these swing House districts, Democratic candidates would need to win the votes of most independent voters, some Republicans and many Democrat-leaning voters who typically don’t show up to vote on Election Day.
Health care reform will be a key issue in every such swing district. No doubt many of the Democratic candidates running in those districts believe that ultimately some kind of universal comprehensive and affordable approach -- including limits on drug prices, expansion of mental health services, and other key components -- is the goal.
But can Democrats win back the House next year, and then the Senate and the White House in 2020, by calling for a government-run single-payer health care system like Canada’s? Or will they do better politically if they reassert the urgent need for affordable health care for every American and support a more incremental approach to fixing the flaws of the Affordable Care Act -- for example, a “public option” that allows consumers to pick either private or government-run health insurance?
The debate over single-payer shouldn’t be an either-or question. Some districts would readily support a single-payer system. But there is no doubt that there are moderate districts whose voters will reject any proposal that resembles a “government-run health care system.” Failing to recognize that could doom any effort to move toward universal comprehensive affordable health care.
A public option is actually a significant expansion of government-run health insurance, but it’s also a step that doesn’t require that people give up the health insurance they currently have.
Without doubt, the Democrats have moved to the left in the past decade, not only over health care but over many other issues. The Sanders campaign helped lift up single-payer and Medicare-for-all into the public debate and other prominent politicians like Sen. Elizabeth Warren are adding their support. That’s a good thing and more should follow. But the American public is still ambivalent and confused about the best approach for themselves and their families, as well as for the country as a whole. The success of the right and GOP at bashing government over the past few decades makes a bold “single-payer now” approach, in every House and Senate race, extremely problematic.
Progressives need to find ways to restore Americans’ trust in activist government as a force for good. To support a single-payer system, they must be convinced that government-run or government-subsidized health care is more effective and efficient that an unregulated private sector. Right now, only one-third of Americans embrace that view.
None of this is an argument against a single-payer health care system. It is an argument to be careful and to be strategic. Single-payer is the correct solution, but without a strategic analysis and a path to get there, progressives will lose and lose badly.
Conservatives are generally smarter than progressives in moving their agenda strategically and steadily to get where they want to go. Progressives only know how to get there in one step.
There is broad unity among progressives, the Democratic Party and many more that every American should have access to health care -- in other words, universal health insurance. How we should get there is where the divides begin. Elections aren’t about detailed policy prescriptions -- they are about assembling enough votes to support a candidate with an aspirational agenda for the country. A one-size-fits-all litmus test will succeed in liberal districts but has a good chance of alienating many voters in conservative and swing districts.
Along with increased trust for government, progressive control of government is an essential pre-condition to achieving universal health care -- whether it is single-payer or soe other form.
If the Democrats gain a majority in the House next year, they will put a wall around the gains made by Obamacare. If they win back the Senate and the White House in 2020, they can have a robust discussion about how to get to universal affordable coverage.
This not a debate over principles. Almost every progressive agrees on the goal. It is a debate over strategy.
There is, in fact, more than one path to accomplish universal comprehensive affordable coverage. Gerard Anderson, Jacob Hacker and Paul Starr have suggested, in a recent article in Health Affairs, that we should allow Medicare to provide insurance to all consumers in counties where fewer than three insurers participate in the Obamacare exchange.
But whether it’s a public option, an incremental expansion of Medicare or other regulatory approaches that expand coverage and prevent profiteering (especially by drug companies), the critical question now is whether the single-payer movement can marry its passion with a smart political and policy strategy to get us from here to a truly universal system that can’t be taken away.