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How Trumpcare’s Failure Sets the Stage for Single-Payer

With the implosion of "repeal and replace," the next logical step in Democratic health care reform is Medicare for All.

Alex Wong/Getty Images

Trumpcare is dead. President Donald Trump is humiliated and so is House Speaker Paul Ryan. The Democrats can hardly believe their luck: The Republicans have hobbled their own agenda, while Obamacare, aka the Affordable Care Act, lives to fight another day. But unlike the law’s previous brushes with death—most notably its bruising encounters with the Supreme Court in 2012 and 2015—this latest example of its resilience represents a turning point, if Democrats choose to seize the opportunity. For three reasons—political, structural, and moral—now is the time for the Democratic Party to begin building a proposal for a single-payer health care system.

Politically, the momentum clearly points left. Long derided by conservatives and centrists as socialist fantasy, single-payer health care (sometimes called Medicare for All) is having a moment. In January, 60 percent of Americans told Pew Research Center they believe the government has a “responsibility” to ensure health care access. That figure tracks with a 2015 Kaiser Health poll, which revealed that 58 percent of voters supported some version of Medicare for All. Democratic Socialists of America have experienced significant membership growth since Trump’s election, and its activists are canvassing for single-payer in New York and California. California gubernatorial candidate Gavin Newsom just added a version of the policy to his campaign platform. And Senator Bernie Sanders reigns as the country’s most popular politician—and he ran in the Democratic primary on a platform that included Medicare for All.

For long-time advocates of single-payer, this is all rare good news. Dr. Steffie Woolhandler, a co-founder of Physicians for a National Health Program, expressed tentative optimism in an interview with the New Republic. “We’ve been getting a lot of requests from professional journals and physicians and professional organizations to speak on the issue of single payer,” she said. “As someone who’s been doing this a long time, I’m seeing a lot of interest about single payer.”

There’s evidence that this is more than an anecdotal observation. Nobody except the White House and the insurance industry wanted Trumpcare. The bill, otherwise known as the American Health Care Act, would have in many ways returned the health care system to the pre-Obamacare status quo. By upending Medicaid and repealing the individual mandate, it would have taken insurance away from tens of millions of people and made it more expensive for the poor, the elderly, and the sick. A Quinnipiac University poll found that 56 percent of Americans opposed the bill, while a mere 17 percent supported it. Not even a majority of Republican voters supported the bill. Critics of the AHCA were outspoken: They swamped congressional offices with phone calls, an outgrowth of earlier town hall disruptions. Trump’s approval ratings sank to a miserable 37 percent.

Trumpcare failed for numerous reasons, starting with the incompetence of President Trump himself and the dysfunction of the Republican Party. But the defeat of Trumpcare points to a deeper, simpler politics surrounding health care. Most voters have no opinion on the efficacy of high-risk pools. They think in expansive terms: They want health care, and they want more of it, not less. Trumpcare threatened that basic interest. If Democrats are to capitalize on this moment, they can’t satisfy themselves with merely preserving Obamacare. The failure of Trumpcare proved that Obamacare is a floor, not a ceiling; in fact, Trump himself helped establish that floor by duping his supporters into believing that “everybody” would be covered under a Republican health care plan. What voters want is better, more generous care, and the smart response is to give it to them.

Is single-payer the policy answer to more and better coverage? Calls for single-payer invariably provoke concern over its practicality and expense, and it is true that single-payer proposals have to account for a drastic transition process. According to the University of Chicago’s Dr. Harold Pollack, there’s no doubt that “a well-functioning single-payer system would work better than the current American health system.” But he said advocates must account for the dysfunctional system they’ve inherited.

“The challenge that I have is that people often talk about single-payer as an alternative to the pathological political economy that drives American health care and American health politics,” he told the New Republic. “And a single-payer system would have to be a product of that exact same troubled political economy, and would have to bake in many of the defects that we have in our current system in order to come about.”

This dynamic is partially why then-President Barack Obama had to fight conservatives in his own party to pass the incremental reforms offered by the ACA. Obama himself became more conservative on the issue: Though he once supported what he called “a single-payer universal health care program,” he came to believe that single-payer would be “too disruptive” for the health care industry.

But this triangulation leaves us a patchwork system for a universal problem. Most Americans still get health insurance from their employers, but this coverage can still be expensive. Qualify for Medicaid, and you have to hope the government will provide the medications your doctor says you need. Qualify for Medicare, and you may still need to purchase supplemental Medicare plans to cover your expenses. If you qualify for neither, and don’t have insurance from an employer, then the ACA’s exchanges are your only option. But if you can’t afford the premium, you’ll have to pay a fine.

The system’s deficiencies are well-known. For one, this thin safety net doesn’t actually save the country any money. The World Bank reports that, in 2014, America spent more on health care as a total share of its GDP than any other nation save for the Marshall Islands. Our health care system is also one of the most inefficient on the planet: Bloomberg reported last September that America ranks 50th out of 55 nations its health care efficiency index. The question is not if the ACA and Medicare and Medicaid are inadequate. This is self-evidently true.

What is new is that Trumpcare’s failure proved, in the most emphatic way possible, that you can’t go further right than the Affordable Care Act without starting to drop people en masse from health insurance coverage. As David Leonhardt pointed out in the New York Times, Democrats have moved right on the issue for decades, culminating in the ACA—if you want to improve health care in this country, there is nowhere else to go but left. That is why the call from centrist liberals for more “market-based” health care reform makes little sense. People object to the status quo; they will not be content with its maintenance.

Pollack, who supports an incrementalist approach to reform, urged single-payer supporters to focus on defending the ACA’s Medicaid expansion and to demand a public option in the Obamacare exchanges, which would theoretically bring down the costs of health care plans in the individual market.

Woolhandler, meanwhile, says the answer is an improved and expanded version of Medicare. “Make the coverage cover all medically necessary services without copayments and deductibles and proscribe the participation of private health insurance industry in the Medicare program,” she suggested. The result, she argued, would be less expensive than America’s current system. Vijay Das, a strategist for the think tank Demos, suggested a similar strategy, with a particular focus on state-based policies. “I think expanding Medicare to children is a safe way of expanding the risk pool, getting healthy people into the system and lowering costs,” he explained.

All these proposals, in their own ways, logically lead toward single-payer. But they face numerous political obstacles, and Das says the Democratic Party is one of them. “It’s partly because the party that used to be the proponent of single-payer has been largely captured by the interests who think single-payer will destroy their profits,” he explained. “For me, it’s a money in politics issue, not as much as a mobilization issue.” As Lee Fang reported for The Intercept last year, Democratic consultants helped raise $1 million to defeat a single-payer proposal in Colorado. The same consultants had links to the Obama administration and the Clinton campaign.

Health care reform is a problem with a dual nature. It’s a matter of policy, yes, but of morality too, and there is an unassailable moral logic for single-payer. Opponents of single-payer must reckon with it, just as they ask advocates to reckon with political practicalities. Advocates must repeatedly ask: Is the status quo tolerable? “Even with the ACA’s advances,” Das said, “it’s really, really difficult to tell somebody who is in and out of work, is working class, and doesn’t qualify for Medicaid, that their $465 a month-even-with-subsidies-premium is something they should be happy about.”

There is a body count attached to every delay and half-measure. On February 17, Amy Schnelle suffered a seizure and died. She was 31 years old, reported WATE 6 of Knoxville, Tennessee, and unable to work due to the severity of her epilepsy. Medicaid covered her treatment and she lived relatively seizure-free—until September 2016, when Medicaid cut off one of her prescriptions. “I couldn’t imagine what would happen if I’m off of my medicine for a week,” she told the news station at the time. “I could roll into seizures.” She appealed the decision, but no luck. Medicaid’s decision can’t be attributed to Donald Trump, either. It occurred under the Obama administration.

Schnelle slipped through the system’s spiderweb cracks. She was lucky to even qualify for Medicaid: States aren’t required to expand it, and the ACA’s subsidies often aren’t generous enough to make up the difference for people who can’t use it. These cracks are numerous enough, and create a void wide enough, that crowd-funding campaigns proliferate as an alternative. In 2015, the Los Angeles Times reported an “uptick” in the use of websites like GoFundMe, Indiegogo, and YouCaring for health care needs. These campaigns bare the desperation of those in need—and the catastrophic consequences of their inadequacies.  After relocating to care for his dying mother, Shane Boyle, a type-1 diabetic, started a GoFundMe campaign to cover a month’s worth of insulin due to a gap in his insurance coverage. His mother died on March 11. Boyle died of diabetic complications one week later, without meeting his fundraising goal. His family has started a new GoFundMe to pay for his funeral.

The moral case for universal health care is too often obscured by red-baiting. But once you accept that everyone should be covered, and establish that the expansion of government programs is the only viable path to achieving that goal, that case is difficult to ignore. Trumpcare’s defeat offers Democrats a chance to move from a defensive crouch to a positive vision that affirms the moral significance of health care as a human right. The market can’t compensate for the system’s deficiencies. In fact, the market is precisely what restricts the ACA’s salvific properties, and that has deadly consequences for the sick. How many Shane Boyles must we accept in deference to it?

The seed is there if Democrats are willing to water it. The Washington Post’s Dave Weigel reported Sunday that Rep. Jim Langevin (D-RI) and House Minority Leader Nancy Pelosi (D-CA) recently told constituents they are either interested in or expressly support single-payer health care. Rep. Keith Ellison (D-MN) is on record supporting Medicare for All, and Sen. Elizabeth Warren (D-MA) also indicated she supports some version of a single-payer system.

They’ll have a test soon: Sanders has announced that he will re-introduce his Medicare for All bill, and a similar measure in the House has 72 co-sponsors. Neither will pass in a Republican Congress, but that’s not really the point. As Ryan Cooper recently argued in The Week, popular support for Medicare means that Medicare for All proposals are “an excellent organizing signpost.” The concept obviously appeals to the party’s base—and could be marketed in a way that appeals to low-income Republicans at odds with the GOP’s austerity.

The Democrats spent years preparing themselves for Obamacare. Now is the time to do the same for single-payer. Now is the time to organize and to develop evidence-based policies they can actually implement when they’re back in power. The transition will cause disruption, but it can and should be managed. The alternative is intolerable. “We need health care,” a West Virginia coal miner told Sanders during an MSNBC town hall earlier this month. “Everybody in this room needs free health care.” He gets it. Sanders gets it. It’s time everyone else did, too.