New York’s Democratic voters sent a new class of true-blue legislators to Albany in 2018. With the governor’s office and both houses of the state legislature firmly under Democratic control—and a raft of progressive bills rapidly signed into law—many hoped this would be the year New York finally enacted single-payer health care.

Health care was, after all, a top concern of voters in 2018, and support for single-payer legislation is strong and growing. One 2018 article suggested that even those running in mixed districts got the message: “Democrats in Swing Districts Run on, Not From, Single-Payer Health Care.”

Yet recent reports indicate that the New York State Senate has no plans to vote on legislation this session, preferring to hold more hearings on a bill that has been proposed in the legislature since 1992. Assembly member Richard Gottfried, whom I interviewed in February, has sponsored the pro-single-payer New York Health Act (NYHA) for nearly 30 years, and the Assembly passed his bill in the past four legislative sessions. But a number of new or re-elected state senators, faced with the fresh possibility that single-payer might actually become a reality, have walked back their formerly full-throated support.

This matters nationally. If a state like New York were to pass single-payer, the nation would arguably follow suit. That is roughly what happened with the Children’s Health Insurance Program, which began at the state level about a decade before it was enshrined in federal law. Much has been made of the Trump administration’s likely refusal to grant a waiver to redirect certain funds to the New York Health Act. But Gottfried said that while federal cooperation would certainly ease the way, “we can do it legally without federal waivers.”

Andrew Gounardes, the young Democratic lawyer who ousted longtime Republican incumbent and police impersonator Marty Golden in November, ran on his support for the NYHA. Questioned at a recent town hall by a woman who wants the bill to pass—“Please,” she said, “from the viewpoint of what it would do for New Yorkers”—Gounardes replied, “The virtues of going into this program are really well established. I’m not doubting that at all, and I think [the recent addition of universal long-term care to the bill] is really a game changer.”

“I’m not trying to spike my support for the New York Health Act,” he continued. “I just want to make sure we’re doing it thoughtfully…. If we don’t get this right, the cause is done.”

Pressed to clarify their positions, Cuomo and a number of Democratic legislators played variations on this tune: Single-payer is ideal, but here and now—at the state level and without the elusive waiver—is not the time or place.

A group of Long Island state senators who supported the bill while campaigning also came down with Gounardes’s post-election reservations. According to Ron Widelec of LI Activists, an Our Revolution affiliate and Long Island chapter of the New York Progressive Action Network, state Senators Anna Kaplan, John Brooks, and James Gaughran sought the group’s endorsement in 2018. (Brooks and Gaughran received it; Kaplan did not.) All three filled out an endorsement form strongly affirming their commitment to single-payer.

Then something changed. As of April, Brooks, Gaughran, Gounardes, and Kaplan have not signed on as co-sponsors of the 2019–20 version of the NYHA. Repeated requests for comment yielded a phone conversation with Brooks, an email from Gounardes’s communications director requesting and ignoring a deadline, and radio silence from the offices of Gaughran and Kaplan.

Despite the recent influx of new blood, old deals seem to be taking place in Albany. After his election, Gounardes became chair of the Senate’s Civil Service and Pensions Committee, a role that requires sensitivity to the concerns of public-sector unions, many of which oppose the bill. In 2018, Cuomo—who has said that the NYHA would “double everybody’s taxes”—endorsed Brooks, Gaughran, Gounardes, and Kaplan. Cuomo’s campaign donated the maximum amount to Brooks, Gaughran, and Kaplan in their primaries.

Cuomo has gained from strengthening alliances with legislators who support cost-free Democratic priorities but oppose or are willing to backtrack on those that require money. He and his allies prefer to avoid inconveniencing wealthy donors or worrying suburban voters. Cuomo fears the rich will flee New York if they have to pay higher taxes. It benefits him to be able to say the legislature doesn’t want to pass legislation perceived as expensive, either.

A coalition of business councils, chambers of commerce, unions, and insurance industry groups called Realities of Single Payer also worked hard to undermine single-payer, declaring that it would be “a financial disaster for New York taxpayers.” An opposition memo issued by the New York State Association of Health Underwriters, a Realities of Single Payer member, blames rising health-care costs on “poor lifestyle choices, not shortcomings in the healthcare system” and claims that “the U.S. Healthcare system is among the best in the world.”

Never mind that recent data shows “the U.S. lags behind similarly wealthy OECD countries”—or that, according to a 2015 economic analysis by the chair of the economics department at the University of Massachusetts at Amherst, “over 98% of New York households would spend less on health care under the Act than they do now.”

Knowing some unions oppose the bill “breaks my heart,” Dr. Martha Livingston told me in a phone conversation. She is the chair of SUNY Old Westbury’s public health department, the vice chair of the NY Metro chapter of Physicians for a National Health Program, and a national board member of the Labor Campaign for Single Payer Healthcare. “I speak as a union activist in my own union,” she said, and “my position and other unions’ position is, if we can get health care off the bargaining table, we can advocate for so much more in our members’ pockets.”

Katie Robbins directs the Campaign for New York Health and works for the New York State Nurses Association, the state’s largest union for registered nurses. The NYSNA and 1199SEIU are the NYHA’s two most powerful union backers. Robbins said in a phone conversation that she and her allies are “disappointed” that public-sector unions oppose the bill. She takes their concerns seriously and has called for “a labor roundtable to work through these issues.” It is, she said, both possible and “necessary” to make the bill work for unions.

State Senator Gustavo Rivera, the chair of the Health Committee and the bill’s sponsor in his chamber, acknowledged in a phone conversation that “attacks from the right” and “resistance from the left” have created “a very narrow path” to passing the NYHA.

Before this year, he said, the bill was always going to pass in the Assembly but not the Senate. So many people, including those “who in good faith have issues with the bill” and those “who don’t want to see their business model destroyed,” were not actively engaged, he said. The fact that they are now “has created some new challenges.”

Divisions over the NYHA exist both within and among unions. Many rank-and-file members have no opinion on or support single-payer at the state level, while many leaders oppose it. The Movement of Rank and File Educators (MORE) is an opposition caucus in the United Federation of Teachers. MORE member Peter Lamphere was blunt about why he thought UFT president Michael Mulgrew supported the Municipal Labor Committee’s decision to send a letter opposing the NYHA to Cuomo, Assembly Speaker Carl Heastie, and Senate Majority Leader Andrea Stewart-Cousins.

“Mulgrew has caved to Cuomo and some of the more conservative elements in the union movement on NYHA,” Lamphere wrote in an email. “MORE has a position in favor of [statewide] single payer and we campaigned on this in the UFT elections.”

Lamphere said the UFT hasn’t had organizationwide discussions of the NYHA. Mulgrew acknowledged in a phone call that individual member concerns about single-payer have “not come up much at meetings.” Instead, he has raised the alarm himself, saying at a December executive board meeting, “We are in support of single payer for the United States. If we enact this in NY State, it will blow a hole in the budget the public schools will not recover from,” and making a similar remark at a UFT meeting in April.

Asked whether UFT members voted to oppose the bill, Mulgrew said the Municipal Labor Committee decided to send an opposition letter, and he was elected to serve on the committee. “You’re an elected rep from your union,” he said. “If you had to, every time you were asked to vote or to give your opinion, stop and go back to your union, you’d never get any of that work done.”

Amid ever-rising health care costs and threats from the Trump administration to repeal the Affordable Care Act, supporters argue that passing the NYHA is critical to ensuring that all New Yorkers have quality, affordable health care—and a future in which everyone living in the United States does, too.

Unfortunately, New York’s governor is not eager to lead the way. In March, Cuomo said that if the legislature passes the NYHA, he will sign it but “no sane person will pass it.” He has essentially dared the legislature to try: “You want to do that? Let’s go…. Every union is against it…. The Civil Service Employees Association is against it. The 1199 health-care union is against it.”

In fact, 1199SEIU and the NYSNA are for it—but they represent predominantly female workforces, perhaps explaining their invisibility to the governor.

The governor likes to imply that on the NYHA, he is taking his cues from labor. It seems likelier that unions wishing to stay in Cuomo’s good graces are taking their cues from him. Mulgrew said in a phone call that the governor’s position did not influence his own: “Absolutely not. I never even spoke to him about it.” But the objections he raised were strikingly similar to those Cuomo has raised, from budget woes to fear of taxes to Trump’s “direct attack on blue states” via capping state and local tax deductions. (Cuomo called the cap “economic civil war.”)

Rivera said that Cuomo does the things he feels are politically necessary to do and that the bill’s supporters need to make him back it.

In the meantime, variations of the same argument have been made for and against the NYHA. Supporters say the bill is necessary to protect New Yorkers, regardless of whether the Democrats are able to implement Medicare for All at the federal level. Others say that the NYHA would only increase instability and that the best way to protect New Yorkers is to demand federal Medicare for All.

State Senator John Brooks, a former insurance industry executive and current legislator who campaigned on the NYHA but has not co-sponsored the current version of the bill, said on the phone, “Depending on what happens at the national level, if the ACA is rescinded and there’s no alternative, what if lots of people with health issues move into New York?”

He still supports the concept of single-payer, he said, but “given what we’re seeing out of Washington with the president’s threat to replace the ACA with an unknown replacement, it’s important to know how this plan is going to work out.”

This echoes long-standing national debates on the left over whether to abolish private insurance or complement it with a single-payer system that covers everyone. Public figures from Harry Truman to Hillary Clinton to Barack Obama have acknowledged the merits of a single-payer system, whether or not they were willing to champion one.

Few New York Democrats openly oppose it. But the New York Health Act won’t pass until they are all willing to fight.

The sad truth is that people living in the United States regularly die from lack of health care and frequently go bankrupt trying not to die. One problem with the current system is that even people with decent jobs and functional health insurance find themselves in these circumstances.

In early March, Candice Hildebrant, a former LI Activists steering committee member, published an essay, “How the Broken U.S. Healthcare System Is Breaking My Family.” Despite the good health insurance she had through her husband’s job, multiple chronic illnesses left her family “drowning” in medical debt, she wrote. Bills like the NYHA, she continued, “will save people’s lives” and help them “get the medical care they need without having to choose between providing for their family or going to the doctor.”

Hildebrant died on March 24 at the age of 35.

“Single-payer is clearly the morally correct choice to make, and we need to be on the right side of history,” Dan Lupkin, a MORE member, told me on the phone. “There is a case to be made, and the union should be making the case for the greater good.”

It’s a case people like Gottfried have been making for decades. But insurance-industry money, tax phobia, political cowardice, and anxiety over scrapping a broken but familiar system remain.

At an April forum on the NYHA at Brooklyn College, attendees carrying orange folders told one of the event organizers they were from the UFT. The folders, which one of the organizers shared, contained 16 pages of background on the bill, drawn from the Realities of Single Payer website, Politico, Vox, and other sources. A section labeled “Questions/comments to make” included, “I read somewhere that New York state would have to raise an additional $139 BILLION in new taxes to start to do this plan. How is that a realistic [sic]?” and language about how the idea of new taxes “makes my blood run cold.”

During the Q&A, audience members asked pointed questions about the bill, mainly about taxes.

“What you ought to care about is how much money leaves your wallet,” Gottfried told one skeptical man. “Under the act, less money will leave your wallet…. The fact that the money, after it leaves your wallet, is called a tax as opposed to a premium and a deductible and a copay—all that means is that the money will be going to an entity that is accountable to you as a voter, as opposed to going to an entity that is accountable to insurance company stockholders.”

A woman said the bill sounded “really expensive” and she didn’t trust New York State, which can’t even “fix the subways” (a phrase suggested in the folder) to run it. She is happy with what she has, she added, and is already “taxed to the max.” A diabetic, she gets free medical supplies under her current plan and doesn’t want to be “forced” into another system. “If it’s not broke,” she said, “don’t fix it. At least for me.”

This year, Cuomo called for a commission to study health care. The Senate is delaying a vote on the NYHA until public hearings are held. But as Truman pointed out while proposing a national health insurance program in 1945, “None of this is really new.”

Single-payer legislation has been studied, debated, proposed, and refined for three-quarters of a century. The only question left is how to make lawmakers do it.