No sin­gle issue pow­ered Democ­rats to midterm vic­to­ries more than health­care. Repub­li­cans were round­ly con­demned for threat­en­ing a return to the pre-Oba­macare denial of cov­er­age for pre-exist­ing con­di­tions. Expan­sion of Med­ic­aid passed in three deep-red states (Ida­ho, Nebras­ka and Utah). Dozens of Democ­rats endorsed plans like Medicare for All, and won.

Democrats just got an electoral mandate to deliver cheaper, higher-quality healthcare. They have to use it, and here’s how.

With a Repub­li­can pres­i­dent and Sen­ate, the fore­cast for mean­ing­ful health­care changes at the fed­er­al lev­el before 2021 remains bleak, but 14 states now have a Demo­c­ra­t­ic ​“tri­fec­ta”: con­trol of both cham­bers of the leg­is­la­ture and the gov­er­nor­ship. Those states can build the mod­el for a uni­ver­sal, humane health­care sys­tem, right?

Hang on. State-based sin­gle-pay­er would require a waiv­er to uti­lize fed­er­al Medicare and Med­ic­aid dol­lars and Oba­macare sub­si­dies. And Don­ald Trump isn’t the like­li­est pres­i­dent to grant such a waiver.

But that should not damp­en hopes for state-lev­el improve­ments in health­care. In fact, by cut­ting costs and increas­ing access, blue states can pave the way for a smoother roll­out of sin­gle-pay­er nation­wide after 2020, should we be so lucky.

Sin­gle-pay­er mere­ly means that the gov­ern­ment would take over the health insur­ance mar­ket. In the­o­ry that’s great, as gov­ern­ment can use the large pool of patients to bar­gain down the cost of health­care. But pri­vate com­pa­nies would still deliv­er treat­ment and med­ica­tions. And those com­pa­nies have aggres­sive­ly con­cen­trat­ed, build­ing near-monop­o­lis­tic bar­gain­ing pow­er.

As Phillip Long­man of the Open Mar­kets Insti­tute has point­ed out, in over 40 per­cent of the coun­try, a sin­gle enti­ty con­trols all local hos­pi­tals. Phar­ma­ceu­ti­cal com­pa­nies have also con­sol­i­dat­ed, and the sup­ply chain for pre­scrip­tion drugs is dom­i­nat­ed by a hand­ful of mid­dle­men. In the most recent quar­ter­ly earn­ings reports, just 10 health­care com­pa­nies earned half the industry’s prof­its, nine of them drug makers.

This has had dra­mat­ic con­se­quences for cost and access. Hos­pi­tals that dom­i­nate regions and drug com­pa­nies with a monop­oly on par­tic­u­lar med­ica­tions can sim­ply raise prices on patients with impuni­ty. And as unprof­itable providers shut down, par­tic­u­lar­ly in rur­al areas, peo­ple can­not get the treat­ment they need.

States can fight this monop­o­liza­tion of health­care; in fact, it’s essen­tial that they do. Even a gov­ern­ment sin­gle pay­er would have dif­fi­cul­ty dic­tat­ing terms to a hos­pi­tal net­work monop­oly that con­trols a large metro area. There sim­ply wouldn’t be an alter­na­tive. That’s to say noth­ing of the polit­i­cal mus­cle large health­care providers can leverage.

But Democ­rats just got an elec­toral man­date to deliv­er cheap­er, high­er-qual­i­ty health­care. They have to use it, and here’s how.

States can reject health sys­tem merg­ers and pro­mote more com­pe­ti­tion. Cal­i­for­nia, for exam­ple, recent­ly passed a law enabling the Depart­ment of Man­aged Health Care to deny merg­ers with an adverse impact on patients.

States can also low­er pre­scrip­tion drug prices. They could res­ur­rect an unsuc­cess­ful 2016 ini­tia­tive in Cal­i­for­nia, which would have reduced the price for all drugs pur­chased by the state — through Med­ic­aid or pub­lic employ­ee health plans — to the lev­el paid by the VA. They also could emu­late Vermont’s law allow­ing whole­sale impor­ta­tion of safe, cheap pre­scrip­tion drugs from Canada.

Phar­ma­cy ben­e­fit man­agers (PBMs), the unher­ald­ed third­par­ty admin­is­tra­tors that nego­ti­ate drug prices for health plans, have been crit­i­cized for skim­ming bil­lions off the top when they nego­ti­ate rebates. Increas­ing trans­paren­cy and mak­ing PBMs a fidu­cia­ry that must act in the best inter­est of their clients can dri­ve down costs; Cal­i­for­nia adopt­ed that this year.

There are even options to lever­age insur­ance mar­kets. Cov­ered Cal­i­for­nia, the state exchange, recent­ly insti­tut­ed a pro­gram that rewards or penal­izes hos­pi­tals and physi­cians based on qual­i­ty of care. That could begin to move giant providers away from preda­to­ry prac­tices that hurt patients. States that con­trol their own exchanges could cre­ate their own stan­dards. And Demo­c­ra­t­ic tri­fec­ta states like Maine and New Jer­sey, which use Health​Care​.gov, could build their own state exchanges, insu­lat­ing them from Don­ald Trump’s attempts to weak­en the law.

In Maine and Kansas, GOP gov­er­nors were the last obsta­cles to expand­ing Med­ic­aid under Oba­macare; the incom­ing Democ­rats will like­ly get that done. Gov­er­nors there, along with new Democ­rats in Michi­gan and Wis­con­sin, could also reverse the imple­men­ta­tion of Med­ic­aid work require­ments, which are designed to restrict access. And more than a dozen state leg­is­la­tures have explored a ​“Med­ic­aid buy-in” con­cept, where res­i­dents who can­not afford pri­vate health insur­ance would be able to pur­chase a low-cost, state-run pub­lic option based on Med­ic­aid rates. (Call it ​“Med­ic­aid for All.”)

These are just some solu­tions avail­able. None of them would cost much to imple­ment — in fact, they’d save states and patients mon­ey by con­strain­ing out­sized provider prof­its. More impor­tant, it puts the coun­try in a bet­ter posi­tion to enact sin­gle-pay­er plans that have a chance of actu­al­ly working.

It will take sub­stan­tial polit­i­cal will to take on entrenched spe­cial inter­ests like hos­pi­tals and drug com­pa­nies. But we saw Repub­li­cans win elec­tions in numer­ous states in 2010 and stop at noth­ing to imple­ment their poli­cies. Democ­rats need to be just as bold.