We Represent the Future

By Adam Gaffney, M.D.
Jacobin, Feb. 26, 2018

When future historians chronicle how Medicare for All was finally won, the current moment may prove to be a crucial turning point in their narratives, albeit one contained, most likely, in the earlier chapters. Scholars will have to probe why single payer emerged with such potency at this moment. Proponents have been steadfastly advancing the cause for decades, but it took Bernie Sanders’s insurgent primary campaign to push single payer into the political spotlight.

And it was only last year, amid all the lurid dysfunction and savagery of Trump’s first months in office, when activists helped thwart the Republicans’ Obamacare repeal efforts while simultaneously achieving a historic advance for Medicare for All. For the first time, single-payer bills won support from a majority of Democrats in the House, and — after Sanders’s new bill launched in September — more than a third of those in the Senate. More and more legislators, it seems, knew which way the wind was blowing.

Why now? Because, as historians might one day note, we are at the intersection of two related crises: one in health care, the other in politics.

The first of these may seem like nothing new. There have been health care injustices in America for as long as America has had a health care system. Hospitals once turned away the poor and uninsured in the throes of illness; facilities were once viciously segregated; reproductive rights were once not much more than aspirations. But we also made progress: from the civil rights era, which realized Medicare and Medicaid, to the passage of the Affordable Care Act (ACA), which expanded insurance coverage to twenty million people. But if American health care used to be so much worse, why is it in crisis now?

In part because, despite such wide-ranging reform, the system’s injustices remain unresolved, pervasive, and deadly.

The figures tell the story. Even without Republican rollbacks, twenty-eight million have no insurance, and, according to the Commonwealth Fund, some forty-one million are underinsured. A substantial portion of the nation — predominantly those of low and middle income and disproportionately people of color — cannot afford to see doctors, pay for medicine, or go to the emergency room.

Families who bought silver plans on the Obamacare marketplace still have $8,292 deductibles, but less than half of American households can cover even a $4,000 deductible. Patients take twice-a-day medications only once, skip doses, or fail to fill their prescriptions to save on co-payments. And of course, people die — tens of thousands of people a year — because they lack coverage.

But the crisis in American health care isn’t simply that the aca didn’t go far enough: it’s that there’s no aca 2.0 available to finish the job. Real progress has been made, but the incremental reforms left us with a deeply inhumane system. Meanwhile, the Right is on the prowl, offering a slew of tired, malicious nostrums about personal responsibility, while liberal reformers have mostly run out of ammunition. But the Left has not, and single payer is now the only potent policy weapon still on the table.

Today’s second crisis comes from the larger political economy. Decades of rising inequality have left a substantial proportion of the population wondering if any politician actually represents them. The unequal health care system only exacerbates the problem: wage stagnation has come with rising health care costs, further squeezing workers’ take-home pay. A recent study in the American Journal of Public Health found that, after accounting for income devoted to health care expenditures, economic inequality is even worse than we thought: these costs effectively push an additional seven million people into poverty.

Discontent with the status quo helps explain the unprecedented success of a democratic socialist in the 2016 primary. But the neoliberal crisis has sparked a resurgence in right-wing populism as well. An odious billionaire has risen to power at the head of a right-wing government that spews pollution, slashes the safety net, vilifies immigrants, and redistributes wealth upwards with great efficiency and vengeance.

We should see the Medicare-for-all movement as a powerful response to both crises. It will transform health care, mandating a social right to equitable care, free at point of use. Everyone in the nation will enjoy comprehensive benefits without provider networks, co-pays, or deductibles.

Almost everyone — sick and well, insured and uninsured — has something to gain from this system. Single payer’s universalism is its strength, and the reason we can win it. But the Medicare-for-all movement is both a means and an end: it will clearly make for a happier and healthier nation, but it can also can become a unifying issue within a larger egalitarian political project at a moment of political crisis.

One day, when we read the history of how, against incredible odds, a single-payer national health program was finally created, we will come upon an early chapter that chronicles how Medicare-for-all advocates survived in the political wilderness. We’ll hear about how activists cut their teeth, built coalitions, crafted policy, drafted bills, won over politicians, launched campaigns, swayed opinions, and mobilized the grassroots. It will tell the story of ordinary people forging a powerful movement; it will tell the story of our present.

Fortunately, the next chapter isn’t so far in the future. It will describe how the movement was tempted by — but ultimately rejected — weak and diversionary counterproposals, how it broadened its base, how it skirmished with powerful corporate lobbies with near-bottomless war chests, and how it finally pushed a robust single-payer health care program onto the national legislative agenda.

Let’s forge ahead, confident as the architect of the National Health Service, Nye Bevan, was when he said that “the tides of history are flowing in our direction, that we are not beaten, that we represent the future...”