Segment 7 – Healthcare Power, Politics & Philosophy

Segment 7 – Healthcare Power, Politics & Philosophy

 

This segment reviews preconditions for having a focused discussion of healthcare reform necessitated by powerful vested interests, and it discusses how to overcome political polarization.

In the first six Segments, we have reviewed the relentless growth of healthcare spending. And how rising costs are literally built into the system as it is now. This review should give us some ideas on how to fix the system.

But before we talk about how to fix the healthcare system, we must first tackle some landmines that lurk beneath the surface. The landmines are power, politics and philosophy. They are the subject of the next 2 Segments.

In this Segment, we will discuss both preconditions necessary for a calm, focused discussion of healthcare reform as well as what I call “loaded” political words. Then in the following Segment we will look at traditional American values and principles that can be brought to bear on resolving the core philosophical dilemma that has kept us from fixing US healthcare all these years.

Let’s start with preconditions. The idea here is that healthcare now comprises 1/6 of the entire US economy. So, there are powerful interests, lots of money, and fierce political convictions that could derail any discussion before it even gets started.

So, I suggest setting preconditions to be agreed on beforehand. Only then can we calmly get into the meat of the discussion. Here are the preconditions.

Slide21

First, for purposes of discussion, let’s agree to keep dollar spending at the 2017 level – no winners, no losers, everything the same.

Second, let’s keep power the same. Keep the AMA, the hospital association, the VA, Health & Human Services, etc. No power struggles.

Third, strive to keep partisan politics out of the discussion. Make it a joint problem-solving project. Give credit where it’s due: to politicians or policy writers who contribute constructively. The motto is: “U.S. spells us.” Healthcare employs 1/6 of us and touches all of us.

Fourth, here’s where I will insert a viewpoint from my 40 years experience as a doctor: Human beings all get the same illnesses, all suffer, all are interconnected mind/body/spirits. I – like all doctors — have taken care of rich and poor, all races and nationalities, religious and non-religious, social outcasts and VIPs, saints and sinners. In a hospital bed or in the doctor’s office, we’re all the same. We should remember, “We’re all in this together”

Lastly, since healthcare is “too big to fail,” whatever is done should be done deliberately, slowly, with monitoring along the way and mid-course corrections when needed. If we accept these preconditions, we can have a Win-Win Discussion.

This kind of discussion should look at Facts, Goals, Values and lastly Methods, the actual Fix.

We have already discussed the Facts. The key facts are:

– the US health system has grown to 3.2 trillion dollars, representing 1/6 of the entire economy

– Cost growth is built into the system, has always outpaced inflation, and has resisted attempts to restrain the growth

– Healthcare spending is draining vitality from the economy, government and individual household budgets

Slide12

Here are the key Goals:

– We must stop excess healthcare growth beyond the natural increase expected from population increase, aging, and innovation.

– To do so will require fundamental reform of the system, not just tinkering with public finance and private insurance

– Since healthcare is “too big to fail”, a key goal is Avoid short-term disruption, again proceed slowly.

Slide13

The last things to discuss before we get to specific Methods – what I am calling the Fix of healthcare – are Politics and Values.

We all know that our country is polarized to an unhealthy extent. This has contributed to political paralysis – not getting anything done. I’m not a political scientist and cannot tackle the whole subject of healthcare politics.

But I do want to look at what I call “loaded words” that creep into our debates on healthcare. These words lock us into a closed, rigid mindset and can shut down discussion.

Let’s look at a few “loaded words” and suggest more neutral words to help keep the discussion open-minded.

Slide16

First is “socialized medicine.” This terminology stirs up the negative connotations of the so-called “Prussian menace” after World War I and “Red scare” after World War II. A more neutral term would be “publicly financed medicine.” The truth of the matter is that currently almost 50% of healthcare is already publicly financed through Medicare, Medicaid and other government programs. The issues behind the loaded words, which do need thoughtful discussion, are accountability; and also advantages and disadvantages of uniformity and nationwide scale, instead of the current fragmented system.

The next loaded terms are “free market” and “competition.” The connotations are freedom from government interference, freedom from politics, consumer freedom, and efficiency. The grain of truth behind the terms is that the law of supply and demand does drive down prices to a balance point in pure markets. The reality, however, is that healthcare is not a pure market, as we saw in Segment 5. Also, markets sometimes leave aside consumers who are poor or powerless, which includes many of the sick. A more neutral term is commercial market.

Next is “rationing.” The connotation is forcibly withholding something from an individual. A more neutral term is “limit-setting” or “prioritizing.” We will talk more about this in the next Segment, and about the need for patients’ to consent to limits on their health service or health insurance. The reality is that we already have de facto rationing by zip code, income level, government budgeting, and hospital technology policies. Prioritizing is not bad – it’s necessary.

Slide18

Another loaded word is “choice.” The connotation is that the government will interfere in choice of doctor or into the doctor-patient relationship itself. This was one of the scare tactics used by the insurance association in 1993 to bring down the President Clinton’s health reform plan. But the reality is that insurance network plans restrict patient choice of doctor more than government rules do. In addition, doctor inclusion in Medicaid – and other insurance plans, for that matter — is often a matter of the pay scales set by Medicaid or insurance companies, not the choices made by patients.

And the last loaded term I’ll mention is “big government.” The connotation goes back to President Reagan saying, “Government is not the solution to the problem; government is the problem.” We always hear about the Army’s 100-dollar toilet seats (in 1986 dollars) and the disastrous roll-out of the Obamacare website.

Slide19

And the truth is that government is big and can be just as flawed as any big institution. However, national government, unlike private companies, is legally transparent and accountable. Also, Government can fulfill some functions more effectively and efficiently than some private sector piecemeal approaches. Here are examples: FAA, FDA, FCC. Currently the military enjoys a high regard. Some examples of public-private partnerships are the moon shot, internet and healthcare research. Medicare has an enviable customer satisfaction rating of 77%.

The reality is that we are now a nation (and world) of big institutions – for-profit, non-profit, government, academic. All have institutional governance and administrative challenges, which are studied by the disciplines of public administration and business administration. Public administration and business administration tell us how best to run big institutions so as to fulfill their mission and to remain accountable and transparent. More neutral terms instead of “big government” are: public sector programs or taxpayer-funded program.

So we have some better neutral terminology to use for discussing healthcare to avoid inflammatory polemical words.

In the next Segment we will look at American values at stake in health care. We will also look at what philosophers say is a fair way to run US healthcare.

I’ll see you then.

 

 

Segment 3 – Healthcare Reform Successes & Failures

Segment 3 – Healthcare Reform Successes & Failures

Slide15

In Segment 2, we looked at the history of medical care in the U.S. until 1965, the year Congress enacted Medicare and Medicaid.

In Segment 3 we will look at reform movements, starting with Medicare and Medicaid. We will look at why later reforms failed and where that leaves us now.

By the early 1960s, nearly all employees were covered by Blue Cross/Blue Shield.

But problems emerged. First, low-wage workers were often not covered by their small businesses, and elderly retirees were not covered. Costs were going up because pre-paid insurance increased patient demand for services. Harry Truman had proposed national health insurance after he surprisingly was re-elected in 1948. But the AMA launched a multi-million-dollar publicity campaign to deride the plan as “Communism” and “socialized medicine.” Truman’s public insurance plan failed.

The next attempt at reform was successful – the 1965 passage of Medicare and Medicaid. Lyndon Johnson succeeded because coverage targeted the uninsured poor-and- elderly, leaving the rest of the private for-profit health system unaffected.

Senator Teddy Kennedy tried in 1971 to extend Johnson’s success to build a single-payer system, and won support from President Nixon. But this plan was derailed by the Watergate scandal.

The next attempt came from Bill and Hillary Clinton. After Clinton took office in 1992, Hillary and expert panels devised a plan for universal coverage including essential benefits and pre-existing conditions with mandated employer insurance and expanded Medicaid. This plan failed because the insurance industry launched a stinging publicity campaign featuring a down-home couple named “Harry and Louise.” Americans also balked at the tax increases needed to fund it.

The Clinton’s failure made it necessary to find another solution to rising costs. Managed care, which had first appeared in 1973, became that solution. And it did work, slowing growth to under 6%. But around the year 2000 came a backlash over mammograms and so-called “drive-by” deliveries, which undermined the ability of managed care to control costs.

What do we make of this history? Here are the main take-aways that help us understand our present health system. First, there has always been a tension between the profit motive in the free marketplace and a health promotion motive. Second, Americans have given special treatments to the health industry in return for medical advances. And third, powerful vested interests (doctors, hospitals, insurance, drug companies) have often used polemics and ideological arguments to defend their favored status, not necessarily actual health outcome data.

Slide09

So, this leaves the US with the largest, most expensive healthcare system in the world. In 2011 shown here it took in payments of 2.7 trillion dollars, mostly private insurance, Medicare, Medicaid and out-of-pocket. The figure for 2015 was 3.2 trillion dollars, representing 1/6 of the entire economy of the entire Gross Domestic Product. Government’s share of payments was almost 50% in 2016.

Slide10

This graph shows the dollars spent in 2011 – mostly on hospitals, doctors, drugs, long-term care. Remember that 25% of this pie graph actually goes to administrative costs, not medical services.

Slide11

In defense of U.S. healthcare, in 2012 then-House-Speaker John Boehner and then Senate Minority Leader Mitch McConnell famously said, “the U.S. has the finest health care system in the world,” and further that “wealthy foreigners flock to the U.S. because of its cutting edge facilities.”

2017-10-13-boehner-mcconnell.png

However, the World Health Organization rates the U.S. 15th in performance (life expectancy and delays in care), and only 37th in overall attainment (including financial and service fairness).

In 2015 the Kaiser Foundation compared the US with 10 other developed countries. Here are their results showing areas in which US is better, equal or lacking.

Here are the Commonwealth Fund’s 20-11 rankings – US is in the middle of the pack for most areas but dead last on several others and overall rank.

Slide14Source: http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

What about “foreigners flocking-for-care”? This pertains to highly specialized treatments available only in certain centers such as Mayo, Cleveland Clinic or Hopkins. Some centers in Florida and Texas do market to wealthy foreigners, who pay the full charge in cash, not discounted insurance rates like the rest or us. Boehner and McConnell pointed to Canadians coming to Michigan hospitals, but the Commonwealth study found that Canada is worst in timeliness and 10th worst overall, just ahead of the US in 11th place, so not surprising.

The further truth is that, according to Centers for Disease Control, 3/4 million Americans go abroad each year for medical treatments, such as for holistic care or dental care, but mostly seeking lower cost.

In the next Segment we will talk about cost, namely how the rising cost of healthcare is affecting our economy, our politics, our society – and some say our very existence.

I’ll see you then.

 

 

 

How Medicare Was Won

https://www.thenation.com/article/how-medicare-was-won/

senior citizens supporting Medicare at the 1964 Democratic National Convention

 

The history of the fight for single-payer health care for the elderly and poor should inform today’s movement to win for Medicare for All.

In August of 1964, 14,000 retirees arrived by the busload in Atlantic City. Representing the National Council of Senior Citizens (NCSC), the former railroad workers, dressmakers, and auto assemblers marched 10 blocks up the fabled New Jersey boardwalk to the Democratic National Convention at the Convention Hall. The group, which was organized and bankrolled by the AFL-CIO, moved en masse in floral housecoats and sandwich boards with slogans like “Our Illnesses Burden Our Families” and “Senior Citizens Vote, Remember Medicare.” They intended to push President Johnson to extend public health insurance to millions of Americans.

Astonishingly, less than a year later, they won. Medicare was signed into law in July of 1965 in Independence, Missouri, at a ceremony attended by former president Harry S. Truman, whose push for national health insurance (NHI) had collapsed nearly two decades before. The landmark law created a public-sector insurance pool for Americans 65 and over, which remains today the closest thing to a robust universal entitlement in the US health-care system. Its successful passage (which also passed Medicaid, to insure the very poor) stands in sharp contrast to multiple failed efforts to install a universal single-payer system.

A half-century later, we’re witnessing the early stages of yet another popular thrust toward single payer, increasingly billed as “Medicare for All.” The nomenclature intends to evoke associations with the popular, trusted program, and is perhaps easier for Americans to latch onto than a phraseology that threatens to trigger a tedious lesson in comparative health policy. But if the conceptual jump from Medicare to Medicare for All can serve as a rough model for achieving universal health care in the United States, we should also look to the history of the social movements that achieved something that then, too, seemed impossible.

No one imagines expanding Medicare to all Americans will be easy. Nothing quite like this has ever been accomplished in the United States. Yes, dozens of peer countries have built coherent, humane, universal health-care systems out of entrenched private ones. Yes, mass movements have won major leftist reforms. Yes, advanced private industries of various nations have been nationalized. But human history offers no examples of these things happening in combination, which is what winning Medicare for All will require.

The most viable push toward NHI in American history crumbled in the late 1940s, ruthlessly crushed by not only insurers and pharmaceutical companies but also the American Medical Association. (Physicians, whose already handsome salaries began to rise in the postwar era, feared the blow that NHI could strike to their paychecks, professional prestige, and autonomy, since a government payer would also reduce their control over prices.) As such, the AMA famously shook down its membership for $25 apiece to fund the multimillion-dollar campaign that injected the phrase “socialized medicine” into mainstream American culture.

In this context, it’s perhaps tempting to view Medicare as a capitulation to industry pressure and political challenges, rather than as evidence they can be flouted. After all, Medicare (and, for that matter, Medicaid) targeted the most vulnerable patients. Many single-payer skeptics insist that Medicare managed to pass because it covered the people private insurance left behind. In his book Harry S. Truman Versus the Medical Lobby: The Genesis of Medicare, historian Monte Poen presents Medicare as a sort of compromise between the unfettered free market and the dashed dreams of the 1940s.

While it’s true that the enactment of Medicare didn’t pose nearly the threat to certain health-care-industry stakeholders that the NHI did or that Medicare for All would, it would be a mistake to fully dismiss its applicability to the current political fight. For one thing, the common talking point that Medicare extended insurance to a population who didn’t have it, rather than squashing existing private infrastructure, doesn’t bear out. A full half of elderly Americans did have private insurance plans when Medicare was signed into law. Commercial health insurers initially opposed the program, and began to support it only when it became clear a large administrative role would be preserved for for-profit insurers.

More importantly, while insurance companies certainly fought against health-care-financing reforms, physicians associations and hospitals are typically considered to have been the more significant opponents—they believed Medicare to be a likely conduit for eventual full-scale single payer (and all the government interference they assumed would come with it), and struck back with more or less the same zeal that they mustered decades earlier. As historian Jill Quadagno puts it, the AMA fought Medicare with “every propaganda tactic it had employed during the Truman era.” Such tactics included a widespread media blitz, advertising in doctors’ offices, and visits to congressmen from physicians in their districts. One tactic, called “Operation Coffee Cup,” deputized physicians’ wives to host ladies’ gatherings, at which they’d play their guests an anti-Medicare PSA starring actor Ronald Reagan.

This time, the AMA and its allies failed, but not for lack of trying. So it’s unfair to ascribe Medicare’s triumph to a lack of industry resistance, which was actually quite strong. The more crucial variable distinguishing Medicare from the NHI battles that fizzled before and since was a mass movement of people demanding it, having coalesced at a moment when powerful liberatory struggles against white supremacy and poverty had transformed what could be deemed politically possible.

Organized labor went all-in for Medicare, which took substantial pressure off unions for their retirees’ mounting health-care costs. Their enthusiasm contrasted with their relationship with universal initiatives before and since, despite their largely supporting most on paper. The reasons for labor’s tepid support for single payer have been debated by historians: For one thing, the unions’ success at collectively bargaining for employer-provided health benefits during the Truman-era reform battles perhaps reduced their motivation to prioritize national health-care solutions, the ongoing absence of which almost certainly highlighted the advantage of union membership. Since the 1970s, ever-rising health-care costs strengthened the case that labor’s interests would be served by removing health-care benefits from tense contract negotiations, but declining labor power during America’s rightward political shift tied them to a Democratic Party establishment unwilling to back single payer during the health-care debates of the 1970s and ’90s.

Today, with a slim majority of congressional Democrats vocally warming up to Medicare for All, and the ACA’s so-called “Cadillac Tax” poised to hit hard-won union-bargained health plans, the pro-labor case for single payer has never been more obvious. Indeed, each of the high-profile wildcat teachers’ strikes widely cited health-care benefits as a central demand. While the AFL-CIO has endorsed single payer, the question of whether workers will rally around Medicare for All they way they did for its namesake could well depend on how the movement’s stakeholders deal with those who stand to be displaced by the streamlining effect of large-scale reform.

But beyond institutional heft or the weight of its endorsements, the most impactful contribution organized labor made to the Medicare fight was a committed army of thousands of boots on the ground, many of them seniors who stood to benefit from the legislation or the family members who worried about how they’d care for them. Even the most precursory survey of 20th-century universal-health-care movements makes their most egregious failure stunningly obvious: They were nearly all top-down operations practically devoid of participation of ordinary people intent on changing the status quo.

By the time the NCSC marched in Atlantic City, this movement was already years in the making. It had been building momentum for the idea that would become Medicare in the 1950s, under a Republican president who, in is 1954 State of the Union address, had affirmed he was “flatly opposed to the socialization of medicine.” Rather than standing by waiting for better electoral luck, the Medicare movement fought to make theirs a winning campaign issue that would help to elect Democrats, not the other way around.

For years, the NCSC spearheaded letter-writing campaigns targeting media outlets and elected officials, and did any media outreach it could. It churned out brochures to counter the messaging of the powerful medical lobby, printing and distributing millions of pamphlets and fliers. As Blue Carstenson, then head of the NCSC, recounted later, “We had to make it a cause and we made it a cause…. We charged the atmosphere like a campaign…. We were always jammed in there and there was a hustle and bustle atmosphere. And when reporters came over they were always impressed by telephones ringing and the wild confusion and this little bitty outfit here that was tackling the whole AMA in a little apartment on Capitol Hill…. This was news. It used to make every reporter chuckle or smile.”

So too did the NCSC learn to push the buttons of electoral politics: It organized groups to testify before Congress about insurance premiums, which rose as much as 35 percent some years, like some ACA marketplace plans. And of course, Carstenson’s formidable elderly army turned out to campaign events. When Democrat George Smathers declined to support Medicare before the 1964 election, NCSC members organized town-hall meetings throughout the state—including one in Fort Lauderdale that was allegedly so successful that the organizers had to upgrade to a bigger venue three different times. Their message made appeals to all ages: Relief for seniors’ medical costs, they argued, will also reduce financial pressure on their working-age children, who’d in turn have more room in the budget to raise their own kids.

If the participants in today’s movement for Medicare for All intend to succeed, they must preempt the imminent counterattack of a health-care industry with far more fortunes at stake than the one their counterparts vanquished in 1965. This will require a mass mobilization of people making themselves seen and heard, whose demands for universal public insurance must reach a fever pitch to force candidates and current officials to capitulate. Doing so will demand a broad variety of tactics, including direct action, canvassing, printed materials, and public events, geared toward not only  persuading regular voters but also inspiring new ones.

Finally, this vision of justice must extend beyond the realm of health care alone. It is nearly impossible to imagine Medicare passing outside the political context set forth by the civil-rights movement, and the so-called War on Poverty. These years-long mobilizations of oppressed people had forced the political reckoning that fostered large-scale reform. It is no coincidence that the New Deal and the Great Society—however short they may have fallen—came about in large bursts rather than undetectable spurts.

Paradigm-shifting reforms have been delivered by broad coalitions confronting a common enemy. It’s up to advocates to compel people living under the US health-care system to see themselves and one another as part of a single constituency, from the poorest uninsured to those saddled with punishing paperwork, office staff chained to bad jobs for benefits, providers-turned-pawns of corporate conglomerates, and expectant mothers bracing themselves for exorbitant out-of-pocket costs atop weeks of unpaid maternity leave. And it must be done in solidarity with struggles on behalf of all oppressed Americans—people of color, the unhoused, the disabled, and others—whose subjugation benefits the very moneyed interests who’d prefer to keep things as they are.

All the evidence tells us that robust universal programs build solidarity, and create an impassioned base that enthusiastically defends them. Once Medicare for All is in place we can expect the same. Until then, it’s up to advocates to compel as many people as possible to envision the radically different society that stands to inherit it—and to accept nothing less.

Socialized Medicine Has Won the Health Care Debate

https://newrepublic.com/article/145067/socialized-medicine-won-health-care-debate

Image result for socialized medicine

 

“It’s coming down to a choice between Federalism vs Socialism,” Senator Lindsey Graham proclaimed on Twitter earlier this week. “I chose Federalism of #GrahamCassidy.” His tweet echoed his words at a press conference days earlier, where he framed his Affordable Care Act repeal bill as the only way “to stop a march toward socialism.”

It’s unclear if the Republican senator realized that he was cribbing from socialist revolutionary Rosa Luxemburg. In a pamphlet composed a century ago while in prison, Luxemburg wrote: “Bourgeois society stands at the crossroads, either transition to socialism or regression into barbarism.” Graham, presumably, didn’t mean to liken his bill to barbarism. But increasingly, those are the terms in which Americans view the health care debate—as a choice between socialism and regression. Republicans have used “socialized medicine” as a bogeyman—and they’ve steadily lost ground on the issue. Despite Graham’s attempts to portray the idea of caring for sick people regardless of their income level as a “nightmare” scenario, just 7 percent of those polled thought Graham-Cassidy would help them.

The repeated rebukes of attempts to undo Obamacare have shown that the average American is no longer moved by the threat of the “S-word.” If we are on a slippery slope toward socialized medicine, it appears that Americans are just fine with that. For the left, there’s a lot to learn from the successful battles against going backward on health care—lessons about how Trump-era politics can be used to push “socialist” policies that move Democrats, and the American public, forward in unexpected ways.

Introduced after the Bernie Sanders Medicare for all bill made its debut with 16 co-sponsors in the Senate, the Graham-Cassidy bill looked all the worse by comparison. Both bills arrived at the end of a summer of activism, a summer that has treated us repeatedly to the sight of people in wheelchairs carted out of the Senate chanting, “No cuts to Medicaid! Save our liberty!” The health care movement has been led by the people directly affected—people with disabilities, in many cases, along with veterans of the AIDS movement. They understood the power of spectacle, initiating those dramatic clashes at the Capitol. They also know better than anyone the inequalities baked into the existing system. Their fighting skills were honed fighting for decades against those who say, implicitly or explicitly, that they don’t deserve care.

Of course, politicians have long been disconnected from the American public on the issue of health care. But the movement to defend Obamacare has drawn into stark relief the difference between what people want and what politicians want to offer. Republicans like Graham banked on the attachment Americans have to the class system we like to pretend doesn’t exist. They played on the idea, honed through decades of dog-whistles, that government programs are always giveaways for the undeserving poor and people of color. As one law professor and conservative columnist complained on Twitter, “Years from now, when your child is denied a liver transplant bc of transplant diversity goals, you’ll be sorry you allowed single-payer.”

In the U.S., we tend to either deny the existence of class or treat it like a set of characteristics divorced from power relations. A Make America Great Again baseball cap, a taste for Budweiser and NASCAR—those, rather than income level or accumulated wealth, are the signifiers of class that we understand. Meritocracy is supposed to be the thing we have instead of class; you can hear it in the endless bipartisan odes to the ability to work hard and achieve anything—including, apparently, a liver transplant if necessary.

Barack Obama and Ben Carson are both heroes of the meritocratic tale, though with a different partisan inflection. Even Sanders falls victim to the meritocratic narrative at times, with his refrain that “No one who works 40 hours a week should be living in poverty.” The implication that comes with Sanders’s qualifier is that there are some people who may, in fact, deserve to be living in poverty. If class is just about some personal preferences rather than structures that maintain inequality, then it’s fine to maintain a healthcare system that treats only those who can afford it. After all, if they just worked harder, they’d have earned that liver.

Graham’s single most tone-deaf argument to sell his bill was drawing an analogy to welfare reform. Welfare reform, of course, was sold to the country by Reagan, Gingrich, and Bill Clinton through fearmongering about undeserving black mothersand “young bucks.” Graham’s rhetoric about the size of the Medicaid budget leaned hard on this analogy, hoping that Americans resented Medicaid as much as they were taught to resent welfare.

Like welfare reform, Graham-Cassidy would have turned Medicaid and the subsidies in the ACA into block grants for the states to manage as they see fit. But the problem with health insurance is that it is designed to be used. The goal of welfare reform was to kick people off of welfare; the goal of healthcare reform was theoretically to get more people onto health insurance plans. Welfare reform increased poverty; Graham and Cassidy didn’t want to admit their bill would do the same. The analogy failed, though it told us a lot about what Republicans think of the people who use Medicaid.

The ham-handed Republican attempts to dismantle the health care system—the “socialism” warnings, the appeals to the selfishness of privileged white folks—have only reinforced the public’s support for government taking care of its citizens. It was telling how, in Monday night’s televised debate between Graham and Cassidy and Senators Sanders and Amy Klobuchar, Graham fell right into a trap, unintentionally proving his opponents’ point about what Americans want. When Sanders asked, “Do you know what the most popular health insurance program in America is? It’s not the private insurance industry,” Graham jumped in like an overeager schoolchild: “It’s Medicare,” he said.


Both Republicans and Democrats have badly misunderstood what makes Obamacare unpopular. What people don’t like are the inequities that still prevail in our health care system, not the fact that “government is too involved.” When Vox’s Sarah Kliff visited Whitley County, Kentucky, to talk to Trump voters who benefited from the ACA, she heard complaints from those buying private insurance with their subsidies that their deductibles were still too high for them to access care. Others, not surprisingly, were angry that the very poor got Medicaid, while they had to pay monthly premiums for care they rarely used. But that anger hasn’t turned them against the program. Medicaid expansion—the “socialized” part of the ACA—remains wildly popular, with 84 percent of those polled by Kaiser Family Foundation saying it’s important to keep the expansion.

The ACA’s means-testing sets up a hierarchy of plans that at times seem calculated to fuel resentment of those getting “free stuff.” It also requires hours of work—I write from personal experience, as a freelancer who has attempted to explain repeatedly that my income varies from month to month and year to year—to prove to the system that you are not getting away with something you haven’t qualified for.

The ways that people have tried to patch the gaps that remain in Obamacare, through charities and crowdfunding, have also highlighted its inequities. As Helaine Olen recently wrote in The Atlantic, charities, too, are often means-testing applicants, while crowdfunding introduces a new kind of means-testing—“means-testing for empathy,” as writer Patrick Blanchfield told me recently. Most GoFundMe or YouCaring campaigns for medical bills don’t go viral; only around 10 percent of them met their stated goals. For those who have a big social media audience, or whose particularly compelling story takes off, crowdfunding might work. But the glut of such campaigns leaves people weighing story against story, deciding who is going to get their donations. It’s health care by popularity contest.

By focusing on the not-good poll numbers for Obamacare, politicians and pundits have missed the whole point: The law didn’t go too far for Americans to get behind. It didn’t go far enough. And while single-payer opponents continue to evoke rationed carelong lines and wait times, and other problems that supposedly plague England or Canada, the public seems well aware that the reality for many Americans is far worse. By their very complaints, the pundits and politicians continually highlight the inequality in the system; the complainers are those who can afford the kind of carethat comes with personal attention, privacy, shorter waits, and avoidance of rubbing elbows with undesirables.

To move forward, then, the single-payer movement should double down on what we learned through this fight: that expanding Medicaid made it harder, not easier, to claim that the program is a “giveaway” to undeserving poor. The willingness of people with disabilities to claim and hold the spotlight—as the New Republic’s Sarah Jones has written—has helped to challenge our preconceptions about who relies on Medicaid ,and to make politicians confront those who will not be served by a market-based program. And the willingness, finally, of politicians to fight publicly for single-payer—rather than mournfully shake their heads and say it will never happen—expands the range of policies that even establishment media is willing to discuss.

Most important, we have learned that the old fearmongering tropes about socialism are no longer enough to whip Republican votes for a major plank of their own platform. If anything, the successful fight should help progressives shed their fears of boldly advocating for what they know is right and working to change public sentiment without endlessly obsessing over potential political pitfalls.

It seems that barbarism, to Graham and his ilk, is the idea that they would lose their right to segregated, high-end care to some undeserving, poor person of color. To the rest of us, however, barbarism is a system that decides who deserves to live or die by the color of their skin, the money in their bank account, the hours that they work, or their ability to work at all. This is now an American consensus. And if socialism is the medicine our system needs, the country is ready to embrace it—even by name.