In the last presidential election, the idea of abolishing private health insurance was confined to the far left of American politics. Now it’s the central argument of the Democratic primary race.
On June 17, 2016, 15 prominent Democratic Party activists and elected officials gathered in a hotel conference room in downtown Phoenix. Their job was to formulate language for the party platform, which would be adopted at the following month’s national convention in Philadelphia. But the platform-drafting committee also had an unspoken mission: to defuse the lingering intraparty tension in the wake of Bernie Sanders’s spirited but unsuccessful primary battle against Hillary Clinton.
The Democrats hadn’t faced convention infighting since 1980, when Senator Edward M. Kennedy challenged the incumbent president, Jimmy Carter, and party leaders hoped to use the process of drafting the platform — the compendium of official positions on policies and issues that the party faithful formally approve at the convention — to head off a similar situation. Sanders, the Vermont senator, had been awarded five of the committee’s 15 seats in order to come up with platform language that would be as unifying and unoffensive as possible.
The fifth session was devoted to health care, and it began innocently enough. “The Democratic Party believes accessible, affordable and high-quality health care is part of the American promise,” the committee’s chairman, the Maryland congressman Elijah Cummings, intoned. Several minutes’ worth of earnest self-congratulation about the Affordable Care Act, the legislative centerpiece of Obama’s presidency, followed. The Republican presidential nominee, Donald Trump, had vowed to eliminate “the disaster known as Obamacare,” which mandated that private insurers offer health-insurance plans to those who otherwise didn’t have access to insurance, and mandated that most uncovered Americans enroll in them. The Democrats in the Phoenix conference room were unanimous in their desire to preserve the A.C.A. and to draft platform language assuring the American public that their nominee, Hillary Clinton, would do just that.
A half-hour into the session, Cummings directed the attendees’ attention to a guest on their computer screen. It was RoseAnn DeMoro, the executive director of National Nurses United, the labor group that for years had been the dominant advocate for a government-run national health care system, also known as “single payer” or “Medicare for All.” DeMoro was Skyping in from Chicago, where she was due to speak that evening at the People’s Summit, a gathering of thousands of Sanders supporters. Sanders had requested that DeMoro be given one of his five seats on the platform-drafting committee but had been overruled by Clinton’s loyalists, most likely because DeMoro’s union had loudly supported Sanders over Clinton.
DeMoro, now 70, tends to wear an intent expression that alternates between amusement and withering skepticism. She dispensed with the pleasantries. Obama’s health care program in many ways, she told the attendees, “has fallen short.” Costs were continuing to go up. Sick people continued to be denied coverage. The legislation’s biggest winners were the insurance and pharmaceutical industries. “We’re urging the Democratic Party to put patients before profits,” DeMoro said, “and to make health care for everyone basically a right.”
The Sanders delegates in the conference room applauded enthusiastically. Later the Clinton adviser Neera Tanden reminded DeMoro that the convention intended to feature stories of people whose lives had been saved by Obamacare. Representative Barbara Lee of California insisted that she and other House Democrats had “fought very hard” for single payer. Their goal now should be to “build upon the Affordable Care Act,” Lee argued.
DeMoro was not having it. Building upon a for-profit plan would only serve to entrench the profiteers, she insisted. For every Obamacare success story Tanden might wish to promote, she told the committee, the nurses could recite a multitude of tragedies. “You are not ever going to corner the nurses into saying it’s adequate,” DeMoro said. “I see the dynamic that’s happening here,” she added, her eyes narrowing. “You think that I’m criticizing the Democratic Party for not fighting hard enough for a single-payer health care system. And I think that’s probably accurate.”
Onstage that evening at the People’s Summit, DeMoro gleefully recounted the rancorous exchange. “They wanted me to say that the Democratic Party fought hard enough,” she told the audience. “But in reality, they didn’t.” Then, to thunderous applause, DeMoro said, “When I appeared by Skype before the committee, I could feel the Bernie movement’s power. I could feel the 58 percent of the American people who support single-payer health care.”
That power was not enough to sway the platform committee, which by a margin of one vote elected not to include any mention of a single-payer system in its 45-page official document. A little more than a month later at the Democratic convention, DeMoro remembers running into Lee. Lee, a liberal from DeMoro’s state, was still stung by her criticism. “Man, you went after me hard!” DeMoro recalls Lee saying. As a state senator in 1998, Lee reminded her, she had co-written a single-payer bill that died in committee. And Lee had, in fact, joined Sanders’s five drafting-committee members in voting to include single-payer language in the party platform.
DeMoro regarded Lee’s efforts as insufficient. The Sanders campaign’s success in making Medicare for All a defining progressive issue, she told me recently, “was a time in history when you knew change had come and the movement was moving past the standard-bearers of the left. It was one of those lead-or-get-out-of-the-way moments. And Barbara was playing an insider game and wasn’t willing to fight.”
Like many progressive activists, DeMoro — who retired from National Nurses United last year but remains an influential voice on the left — views her movement’s proximate adversary as the Democratic establishment rather than Trump’s Republicans. Of late, she has devoted much of her social-media energy to deriding Senator Kamala Harris, whom she has called “Chameleon Harris” on Twitter. A longtime resident of the Bay Area, DeMoro viewed Harris more or less favorably when she was California’s attorney general. But as Sanders’s presidential opponent, she had, to DeMoro’s thinking, revealed herself to be a transparently calculating triangulator: “There’s no there there.”
The day before the second round of Democratic presidential debates in Detroit, Harris’s campaign announced her new health care plan, which would guarantee universal coverage but also keep private insurers. Even though the plan was not a single-payer system, Harris had nonetheless felt compelled to call it Medicare for All. Three weeks later, however, she would tell her donors, “I’ve not been comfortable with Bernie’s plan, the Medicare for All plan.”
The contortions suggested how much the politics of health care among Democrats had changed — and how much Sanders and DeMoro had changed them. In a party that three short years ago kept single-payer advocates at Skyping distance, Medicare for All now sits at the head of the table, pulling the Democrats decisively leftward. Sanders’s Medicare for All bill in the Senate has 16 co-sponsors. In the House of Representatives, Pramila Jayapal, who is the co-chairwoman of the Progressive Caucus, has introduced a health care bill with 117 Democratic co-sponsors that is even more lavish in its benefits (and thus probably costlier) than the plan Sanders has put forward in the Senate; it, too, is called Medicare for All. In addition to Harris, two other presidential candidates have offered health care plans that pilfer from Sanders in name if not in substance: Pete Buttigieg, with Medicare for All Who Want It; and Beto O’Rourke, with Medicare for America — the latter borrowing from a proposal developed by Neera Tanden’s Center for American Progress, itself called Medicare Extra for All. The idea’s original advocates, like DeMoro and Sanders, after years of struggling to get into the mainstream Democratic policy debate, suddenly have an embarrassment of allies — or at least people who claim as much. “Medicare for All shouldn’t mean all things to all people,” Warren Gunnels, Sanders’s senior campaign adviser, told me. “It’s single payer. Everybody else’s program is Medicare for Some.”
Medicare for All, as envisioned by Sanders in a 2017 Senate bill, would expand coverage in phases over a four-year period. Drug co-payments would not exceed $200 a year. The overall cost of the plan would be roughly $30 trillion over a decade. According to an analysis by the University of Massachusetts Amherst’s Political Economy Research Institute, that amount would be largely offset through savings in areas such as administrative overhead, pharmaceutical costs and physician salaries. A combination of payroll, sales, capital gains and income taxes could pay for the remainder. The result would be a government-run health care system in which Americans of all ages are covered, are able to select whichever doctor they choose and incur almost no out-of-pocket expenses.
Not since the Great Society era has so ambitious a social program been so actively promoted by influential Democrats. Whether this is a good thing, both as a matter of policy and for a party longing to defeat Trump next year, is currently at issue. On the one hand, the predominance of health care as a voting concern typically favors Democrats; as Sanders’s pollster Ben Tulchin put it to me, “When the conversation is about health care, we’re already winning.”
Single-payer advocates achieved a victory of a sort in the July 30 Democratic presidential debate in Detroit, when the CNN moderator Jake Tapper said, “Let’s start the debate with the No. 1 issue for Democratic voters, health care — and Senator Sanders, let’s start with you.” The 10 candidates onstage discussed Medicare for All for the next 20 minutes — longer than any other issue.
It was an establishing shot that lingered even when the night’s camera frame panned over to immigration and climate change. A couple days after the debate, an ABC News/Ipsos poll showed that when Democratic voters watched both a video of Sanders explaining the virtues of Medicare for All and a video of the front-runner Joe Biden arguing for simply improving Obamacare, 31 percent found the Sanders plan “very convincing,” while only 18 percent said the same of Biden’s position.
A few days later, however, a Monmouth University poll of likely Democratic caucusgoers in Iowa found that 56 percent preferred the option to receive Medicare, as opposed to a mere 21 percent favoring a government-run plan that abolished private insurance. It underscored the fears of Democrats on the center-left that the issue will boomerang on them in 2020 — that campaigning on an entirely government-run health care system, the creation of which would remove about 156 million Americans from their employer-based plans, according to a Kaiser Family Foundation analysis, will invite an electoral backlash. “It’s been the case of health care policy for decades,” Tanden told me. “If a health care plan is perceived to be about protecting something, it’s usually good. If it’s about losing something, it’s usually toxic.”
Eighteen percent of the United States economy, or $3.5 trillion, is tied to health care, up from 5 percent in 1960. The United States spends at least double per capita what other industrialized nations spend on health care. The health sector is among America’s most profitable industries. And despite the vast profits and expenditures, the United States has comparatively worse health outcomes than other advanced nations that spend far less on health care: higher overall mortality rates, higher premature deaths and higher preventable deaths — all on top of the fact that two-thirds of all bankruptcies and nearly half of all foreclosures in America today are related to medical costs.
In spite of these dismal returns, the health care system has proved extraordinarily resistant to disruption — no doubt in part because of the uniquely palpable stakes. “Health care is unlike any other issue,” Tanden says. “People feel an expertise about it, because they’ve lived it. It’s very personal to them: They think of the care of their child, of their aging parents, of their own vulnerability.”
Though highly attuned to the health care system’s deficiencies, the public has also been fretful that their political leaders will only succeed in making a flawed system worse. For a quarter century, Gallup polls have found that almost without exception, 65 to 73 percent of Americans believe the health care system to be in a state of crisis or having major problems. The same polls observed Republicans feeling especially dire starting in 2010, while conservatives were condemning Obamacare; and Democratic fears spiked in 2018, after Obamacare narrowly escaped repeal by congressional Republicans.
Those sentiments might suggest that Americans would prefer the government to leave well enough alone. But at a moment when a reconsideration of the party’s staid politics is already brewing, they might just as easily be interpreted as a call to arms: a rationale for burning down the system and starting anew.
“I’m not an incrementalist,” DeMoro told me one afternoon at a pizza restaurant in Napa, where she now lives in retirement. “I firmly believe that change happens through rupturing. Trump’s a prime example of that. And the Democrats have used Trump as an excuse not to have a platform of their own. Well, Bernie’s running for systemic change.”
DeMoro became the executive director of the California Nurses Association in 1993. The daughter of the owners of a pizza parlor and a beauty salon in St. Louis, she had never worked in the medical profession. She was fluent in political theory as well as in blue-collar issues and had become close with two of the most tenacious grass-roots activists in postwar American history: the labor organizer Tony Mazzocchi, who successfully agitated for passage of the Occupational Safety and Health Act of 1970; and Ralph Nader, who prodded Congress to pass the Consumer Product Safety Act into law in 1972. “She was steeped in the history of the labor movement, had a critical mind and locked horns with everybody,” Nader recalls. “She would trash the A.F.L.-C.I.O. for lacking substance and courage. But she also really understood the issues. I thought she was the greatest labor leader out there.”
DeMoro took her post shortly after Bill Clinton was elected president, at a moment when rupture seemed imminent in the American health care system. The number of uninsured Americans under 65 had risen steadily from 33.4 million in 1989 to 37.1 million in 1992. (It would be 41.6 million in 2004.) This troubled a Washington State congressman and former child psychiatrist named Jim McDermott. As a medical-school student in the early 1960s, McDermott watched with interest as Canada built its single-payer system while, he recalled, “the American Medical Association leadership predicted that this was the end of the profession, socialized medicine, blah blah blah. Then they said the same about Medicare, until it became a goddamned cash cow for doctors.”
By 1993, McDermott was single payer’s leading champion in Congress. That same year, he put forward a single-payer bill in the House. (Among its 90 co-sponsors was an obscure Vermont freshman named Bernie Sanders.) “Then Clinton came into office,” McDermott told me recently. “Mrs. Clinton needed my 90 votes for their health care plan. She didn’t want to have anything that looked like socialism. She said, ‘Jim, you want to take out the insurance industry, but it’s deeply embedded in our society.’ ”
McDermott gamely offered his support. But Hillary Clinton’s determination to preserve the private insurance system was not enough to assuage Republicans or health care industry lobbyists. The 1,342-page Clinton plan known as “Hillarycare,” which required employers to either provide insurance or pay a penalty that would finance insurance exchanges, was demonized by the health-insurance industry’s “Harry and Louise” TV ads as a wallet-busting bureaucracy that would eliminate Americans’ right to choose their doctors.
The Democrats abandoned their efforts six weeks before the 1994 midterm elections so as to minimize the political damage. In the years that followed, health care costs rose and coverage rates fell. In 1999, medical expenses consumed 14 percent, on average, of American’s take-home pay. By 2017, that figure would more than double, to 31 percent.
These costs ballooned despite the health care industry’s efforts to maximize efficiency through a “managed care” approach, restructuring hospitals and clinics as health maintenance organizations, or H.M.O.s. Under the H.M.O. model, nurses found themselves losing status, leverage and in some cases their jobs. Those who remained employed often found their jobs transformed. “We as nurses were expected to get ’em out fast and move on,” Elizabeth Pataki, a former nurse and labor activist (and cousin of New York’s former governor George Pataki), recalls. “It was heartbreaking to see how little care they were getting and how so many of them couldn’t pay their deductibles, how their premiums were becoming ruinous, how they would ration their medicine by breaking it in half.”
That was the landscape DeMoro encountered as she led the undersize 17,000-member California Nurses Association into the fight against what she would term “the commodification of health.” She spent hours on picket lines with the nurses and absorbed their eyewitness grievances. In the male-dominated world of union leadership, the C.N.A. president stood out. “Nurses of a certain age like me didn’t have role models back then, except perhaps nuns and teachers,” Pataki says. “But RoseAnn, for many of us, showed what it meant to be a woman of commitment, to be warm and funny but also dedicated and direct. I could see where we could go with her.”
They did not go very far at first. In 1994, DeMoro’s California-based union pushed the State Legislature to adopt a single-payer bill, to no avail. Two years later, DeMoro’s union promoted Proposition 216, which aimed to curb the ability of hospitals and H.M.O.s to restrict coverage, only to be bombarded by TV ads (paid for by a coalition of H.M.O.s and business affiliates) conceived by the same political consultants whose “Harry and Louise” ads were used to defeat Clinton’s health care initiative.
The 2008 presidential campaign offered fleeting hopes for single-payer advocates. As a state senator in 2003, Barack Obama proclaimed himself to be “a proponent of a single-payer universal health care program.” Late in the summer of 2007, DeMoro remembers receiving a call from an Obama campaign staff member. The candidate was coming to the Bay Area, the staff member said. Would she like to spend the day driving around with him and discussing health care?
DeMoro agreed. But in typical fashion, she commissioned radio advertisements on the eve of Obama’s arrival, urging the candidate to openly advocate for a single-payer system. “I got a call from one of his people, asking, ‘Did you guys do this ad?’ ” she recalled. “And when I said it was us, they canceled the visit.”
Her union, which by 2008 had grown to around 100,000 members, nonetheless held events around the country for Obama. But in office, DeMoro told me, Obama “proved that he had learned exactly the wrong lesson from Hillarycare.” Insurance and pharmaceutical companies who viewed single payer as an apocalyptic proposition were awarded seats at the table, as were Republican senators.
“Barack said, ‘I don’t want to just message this issue, I want to get something done,’ ” Tom Daschle, Obama’s early pick for Health and Human Services secretary, told me. “The view was that if we started more moderately and reached out to Republicans with something they supported in the past, we’d have something we could accomplish. There were some who believed that Medicare was a good brand that we could expand on. But he didn’t believe Republicans were likely to join that effort.”
The question was whether Republicans were likely to join any effort. The party had been staunchly opposed to government health care expansions, including Medicare, for half a century, arguing instead for market-driven solutions, tax credits and restricting malpractice claims. (An exception to this was when President George W. Bush successfully pushed to extend Medicare coverage to include prescription drugs in 2003 — an industry-friendly initiative that was interpreted by some as a means of shoring up the president’s support among senior citizens in advance of the 2004 election.)
In practice, however, Republican lawmakers have struggled to reconcile what Ronald Reagan termed “the magic of the marketplace” with tens of millions of Americans’ inability to pay for adequate health care. Obama forced the issue by proposing a health care reform built on the bones of a 20-year-old market-based proposal from the conservative Heritage Foundation. “My line at the time,” Charlie Dent, a moderate Republican congressman from Pennsylvania who retired last year, told me, “was that every American had a right to have access to affordable health care insurance.”
The more expedient option was for Dent’s party to weaponize the issue. Obama and congressional Democrats spent a year and a half trying to engage Republicans on health care, along the way discarding one preferred policy option after the next in hopes of forging a bipartisan agreement.
Max Baucus, the Montana Democrat who was chairman of the Senate Finance Committee at the time and led the negotiating effort, had visited a Canadian hospital and was an admirer of that country’s health care system. Still, when he began committee meetings on health care in late 2008, “I told them, ‘Let’s find a uniquely American solution,’ ” he recalled. “ ‘And nothing’s off the table.’ The only exception to that I made was single payer. I thought our country was just not ready for it. I assumed that if we worked together in good faith that over time, we’d naturally evolve toward that kind of system.”
A few of the Republican senators on the committee, like Chuck Grassley of Iowa and Olympia Snowe of Maine, were active participants in Baucus’s meetings. Eventually, however, the Senate minority leader Mitch McConnell made clear his desire not to hand the new president any legislative victories.
“The Republicans started calling it Obamacare,” Baucus said, “and it tapped into a significant portion of the electorate’s opposition to the president. It was political in the end: ‘Hey, we can run against this thing.’ Grassley was under immense pressure from McConnell, who threatened to primary him if he stayed with this. He told me that, flat out.” (Spokespeople for Grassley and McConnell adamantly deny that McConnell applied any pressure on Grassley.) The Affordable Care Act passed in March 2010 without a single Republican vote.
In March 2015, Sanders paid a visit to DeMoro. Their relationship began in 1981 when DeMoro, then a graduate student at the University of California, Santa Barbara, contributed $20 to Sanders’s first campaign for mayor of Burlington, Vt. (Sanders won by 10 votes.) As mayor, Sanders became convinced, through conversations with physicians in Canada, that a single-payer system was the only sustainable means of delivering universal health care. Like DeMoro, he condemned any system that preserved a profit-dominated model, including what would later be known as the public option, as one that would inevitably shortchange patient care.
Now he told DeMoro that he was thinking seriously of running for president as a Democrat. Knowing that he would be heavily outspent by Hillary Clinton and her allies, he wanted DeMoro’s opinion as to whether he could count on grass-roots support. By that point, the California Nurses Association had joined together with other nursing unions in an umbrella organization, the more than 150,000-member National Nurses United, with DeMoro at its helm. Although DeMoro doubted that Sanders had much of a chance, she saw his candidacy as an opportunity to elevate the single-payer issue. In August, her organization became the first major union to endorse Sanders.
Sanders, as a presidential candidate, was an outlier’s outlier, and single payer had been deemed political kryptonite by the Democratic establishment. But DeMoro’s union bankrolled a series of surveys and focus groups by Sanders’s pollster Ben Tulchin. Tulchin was a rueful admirer of the conservative movement’s ability to frame policies in memorable ways: rebranding the estate tax as a “death tax,” for example, or slashing government programs for the poor in the name of promoting “freedom.” Democrats were too equivocal in how they framed their ideology, in Tulchin’s view. He sought to change that by devising a crisper way to sell a government-run health care system to the public.
The rebranding efforts by Tulchin happened to coincide with a gathering of progressive discontent. Throughout the 1990s, the left had more or less abided the Clinton administration’s apologetic view of big government as the cost of staying in power. In 2008, after eight years of Bush’s promoting tax cuts for the wealthy, threatening to constitutionally forbid gay marriage and waging two costly wars, progressives believed their moment had arrived and saw in Obama a new champion. But his legislative efforts proved to fall well short of revolutionary. While admonishing the left to play along and accept one moldy half-loaf after another — on the economic stimulus, on climate change, on gun control, on immigration and on several judicial appointments — the Obama White House’s varied attempts to attract Republican support met only scorn.
To many progressives, Obamacare represented the apotheosis of this strategic folly. The president’s health care initiative played by the private sector’s rules, to the pharmaceutical industry’s conspicuous benefit. And then free-market Republicans rewarded this gesture of conciliation by bashing Democrats as socialists while methodically eviscerating the program on both the state and federal levels. When in 2012 it appeared that the conservative-dominated Supreme Court might declare the A.C.A. to be unconstitutional, DeMoro led the nurses’ union on a bus tour to make the case that the time had arrived for a robust, lawsuit-proof single-payer system. The campaign was premature, however: Chief Justice John Roberts cast the tiebreaking vote in favor of Obamacare, and again progressives were compelled to leave the fight. They watched red-faced in the 2014 midterms as some of the Democratic Party’s most cautious-minded legislators were labeled big-government liberals, enabling the G.O.P. to retake the Senate. By the time the party machinery began clearing the way for Hillary Clinton’s nomination, the left had grown tired of shutting up and was now looking to a dyspeptic 74-year-old Vermont socialist as their avatar.
As Tulchin conducted his public-opinion research to address the question of how Sanders might frame his health care initiative, he hit on an answer that was hiding in plain sight. It came from the legacy of Lyndon B. Johnson, who as president had pushed Medicare and Medicaid through Congress. As Tulchin told me: “The reality is, people know what Medicare is, and it’s very popular and seen as very effective. It’s a true success story for the left. Whereas no one knows what single payer is.”
Tulchin’s findings convinced the Sanders campaign to recast single payer as “Medicare for All” — a name that had previously appeared on a 2006 health care bill written by Senator Edward M. Kennedy that included a role for private insurers. (Kennedy had been an early proponent of single payer but had come to believe that opposition from the insurance industry would doom its chances.) Sanders and DeMoro knew that the word “Medicare” would register favorably among older Americans. They had not anticipated the issue’s overwhelming popularity — close to 70 percent, according to recent polling — among millennial voters. “This had been a gray-haired movement for decades,” DeMoro told me. “It surprised all of us how resonant the issue was with young people.”
Sanders’s early campaign events were packed, in no small measure because of the mobilizing efforts of the ubiquitous union members dressed in National Nurses United’s trademark red hospital scrubs. The union’s political-action committee purchased more than several million dollars’ worth of print and TV ads. Sanders, meanwhile, occasionally called DeMoro from the campaign trail to enlist her help in demystifying the arcane mechanics of the health care industry. “When a single-payer system is finally enacted in the U.S.,” he told an aide, “RoseAnn DeMoro and the nurses are going to be the heroes of this fight.”
Although the Democratic platform committee shunted aside Medicare for All in favor of preserving the Affordable Care Act, Trump’s shocking victory in November shifted the ground again. The longstanding efforts by G.O.P. state officeholders and the Republican-controlled Congress to chip away at the A.C.A. now had an eager partner in the White House.
Shortly after the election, Sanders persuaded the Senate minority leader, Chuck Schumer, to borrow a page from Sanders’s 2016 campaign and stage pro-Obamacare rallies across the country. Those health care events — the first of them on Jan. 15, 2017, with Sanders, Schumer and other Democrats speaking before 6,000 people in Warren, Mich. — began a counteroffensive that ultimately thwarted the G.O.P.’s ambitions of repealing Obamacare.
The rallies, and the crowds they drew, suggested how the politics of health care were changing, and how quickly. Trump and congressional Republicans spent most of his first year in office working relentlessly to repeal Obamacare, an effort that barely fell short in the Senate in August. Republican governors picked up the gauntlet: by December 2018, 20 states had joined a lawsuit seeking to weaken Obamacare.
The imperiling of the Affordable Care Act had unintended consequences. One was that, after years of unpopularity, the law began polling favorably. In the 2018 midterms, it was the Republicans who were on the defensive and stammering that, well, sure, there were a few good things about Obamacare and they could be counted on to protect those things. “I’m taking on both parties and fighting for those with pre-existing conditions,” the California Republican congressman Dana Rohrabacher claimed in a TV ad, despite having voted repeatedly to gut or repeal Obamacare. Voters did not seem to buy the G.O.P.’s protestations. Exit polls following the November 2018 midterm elections, in which Republicans lost 38 seats — including Rohrabacher’s — and control of the House, showed that health care was the top concern.
But the vulnerability of Obamacare also served to underscore the case for a more resilient and comprehensive health care system of the sort that Sanders had been calling for. Medicare for All had become not merely a pet cause among the party’s progressive base but a defining one. It had also become a succinct representation to voters of what Democrats aspired to do for them that Trump’s Republicans would not.
That it had fallen to Sanders to rally Democrats to save what he found an inferior health care policy was a peculiarity not lost on Sanders, who growled to me: “I don’t think anyone will tell you that in any way single payer was seriously considered. In fact, until this year there’s never even been a goddamned hearing on single payer!” The first such hearing took place on April 30, but under the auspices of the House Rules Committee, which has no legislative jurisdiction on health care. A more meaningful second hearing was convened before the powerful House Ways and Means Committee two months later.
‘It surprised all of us how resonant the issue was with young people.’
The hearings were in a sense a validation of Medicare for All’s newfound legitimacy within the mainstream of the party, but they also demonstrated the party leaders’ wariness of the idea. The Democratic Ways and Means chairman, Richard Neal — who received nearly $550,000 in the 2018 election cycle from the health insurance and pharmaceutical industries — had already stated his preference for “a little more incremental” expansion of health care. According to The Intercept, Neal urged his fellow Democratic committee members beforehand to consider using phrases like “universal health coverage” rather than “Medicare for All.”
On one level, these are academic debates. Unless Democrats can break the Republican lock on the Senate in 2020 — a longer-odds proposition than winning the presidential election — they will have no chance of passing any laws, let alone an overhaul of health care far more sweeping than the A.C.A., which Democrats barely managed to enact with a majority in the Senate.
But on another level, the debate isn’t academic at all. It is in fact at the core of the liberal-versus-pragmatic argument among the Democratic presidential candidates, with the former vice president Biden on one end, flashing his battle scars from the Obamacare fight, and Sanders and Warren on the other, arguing that a populist movement now demands more than minor tweaks to a fundamentally flawed health care system. And indeed, on Aug. 21 Sanders tacitly acknowledged the challenge in passing so drastic a change in policy: His campaign announced that his Medicare for All plan had been modified to ensure that union workers who had already negotiated satisfactory health-insurance plans would be compensated for whatever wage increases they had sacrificed in the process.
Several health care experts with whom I spoke consider the Sanders plan, strictly as a matter of policy, to be an entirely reasonable health care solution for America. “The U.S. is an outlier in the rest of the developed world in not having universal coverage and for having such high-cost health care,” Larry Levitt, the nonpartisan Kaiser Family Foundation’s executive vice president for health policy, told me.
Sanders’s proposal “would be an enormous shift in how we pay for health care, and you have to make a lot of assumptions about how that would work, with a lot of uncertainty,” Levitt continued. “For example, how far down could prices for hospitals, physicians and drugs be pushed? How much more health care would people use if we had universal coverage with no deductibles and co-pays? And how well could the supply of hospitals and doctors adjust to an increase in use of health care? There’s a lot of uncertainty to how all of this would play out. But there’s a fair amount of consensus among economists who’ve looked at it that we could provide universal coverage through a Medicare-for-All-type plan and not pay much more for than we’re currently paying.”
Still, the change would be monumental. “The Sanders proposal would leapfrog every country in the world in creating a more liberal health care system,” Levitt said. “Every other system with universal coverage has at least some out-of-pocket costs for patients. And almost every other country still allows for private insurance.” And insurance companies in Europe, for instance, are often nonprofit, highly regulated and with little to no political power. American insurance companies are a different story, and it seems fair to conjecture that they will not forsake their billions in net earnings without a fight.
Though polling does not reflect an outpouring of love for private insurance, it is the devil Americans know. “There’s fear of change and comfort with what’s known, a bias toward the status quo, and it’s hard to quantify that,” says Topher Spiro, the Center for American Progress’s vice president for health policy. “There’s a real psychological issue that’s appropriate for policymakers to consider. I don’t think the people like us who are putting forth multipayer universal systems are doing so because we think insurers have some sort of superior efficiency or can improve the quality of care. It’s really a concern about how we get there the quickest in terms of political viability and with a minimum of disruption.”
Single-payer advocates play down the difficulty of transitioning into a government-run health care system. As Sanders puts it: “You have Medicare, a popular system that millions of people are already in. It seems to me the easiest way forward to get to universal care is to expand what’s already a popular system. I find it really amazing that people think this isn’t doable when back in 1965 they did Medicare without the technology we have today, and they were able to sign up 19 million people. So of course we can do it.”
But while the Republican efforts to gut Obamacare have bolstered support for a more ambitious health care policy, they have also clearly illustrated one potential downside of such a policy. “Medicare cuts are in Trump’s budget,” Tanden says. “If you’re worried about a Trump administration now, just imagine if the government has control of everyone’s health care. And I say that as a big-government liberal.”
The day before Sanders took to the debate stage in Detroit to defend Medicare for All, I met with him in a conference room at the Doubletree Suites hotel where he was staying. He was seated alone, wearing his customary off-the-rack navy suit and tieless white shirt, flanked by a Starbucks breakfast of coffee, granola and yogurt.
“We’ve got a health care crisis in this country,” he told me as he struggled with the plastic granola container, finally gouging it open with his car keys. Sanders has a reputation for being as beatific as a snapping turtle, but today he was happy(ish) to be discussing the topic that he and DeMoro had succeeded in crowbarring into the national debate. “You’ve heard me talk about F.D.R. in 1944 talking about economic rights as a human right,” he said. “That’s what we’re doing here, and I think with some success: changing consciousness in this country. Now everybody agrees health care is a human right. How you get there is subject to discussion. But that’s where we are.”
Recently Sanders had been campaigning in Las Vegas. While driving through the city, he marveled at the billboards advertising marijuana for sale. “Five years ago, corporations marketing marijuana would have been out of the question,” he said to the aides in his car. “Now they’re not only doing it, but it’s not even remarkable that they’re doing it. Politics change very quickly.”
A not-so-minor refinement to that thought would be: Politics change quickly as long as nothing is standing in the way. Nearly three decades have passed since Sanders and DeMoro began doing battle with the health industry and the political system. “What they do have is, they lie and they have an enormous amount of money — I get that,” Sanders conceded. “But I do think we’re at a moment in history where the American people are sick and tired of the insurance companies and drug companies. And I do believe we can beat them.”
For any movement, the answer to the question of how is not really legislative. The Rev. Martin Luther King Jr. had his dream. RoseAnn DeMoro told me hers recently. “I think it’s time now,” she said, smirking a bit as she studied her glass of white wine. “I think America needs to say to these C.E.O.s: ‘You’ve had your day. You’ve bought your 50 frigging yachts. But it’s over. Now let’s have health care in this country.’ ”
HENRY KOTULA 