Written By Brian Beutler

Voters in multiple states that rejected the Affordable Care Act’s Medicaid expansion will have an opportunity this November to adopt the expansion by ballot initiative.

Some states that have expanded Medicaid are now exploring models that would make public insurance programs like Medicaid available to all residents. In Virginia, where Democrats just won a landslide election, Republicans may finally relent and adopt the Medicaid expansion, though only under onerous conditions, like a work requirement, that Democrats would likely seek to abolish later.

In Washington, D.C., last week, the liberal Center for American Progress—generally understood to be the default think tank of the Democratic establishment—introduced a plan that would gradually transform the American health care system into single payer by enrolling newborns and the uninsured, along with individual-market customers, into a Medicare-like program, which would eventually overtake other public systems.

Meanwhile, after successfully wiping out Obamacare’s individual mandate penalty, the Trump administration is recommitting itself to the goal of sabotaging the ACA’s private health insurance expansion. It recently proposed a rule to undermine the quality of health plans by allowing the uninsured to enroll in skimpy short-term policies, and is turning a blind eye to an unlawful Idaho effort to ignore the ACA’s cornerstone rules, including its anti-discrimination protection for people with pre-existing conditions.

These countervailing trends might seem unrelated, but they are not. Rather, the GOP’s unremitting hostility to Obamacare has made accepting a more robust role for public insurance the only plausible path to universal coverage. Now even the most overcautious and conflicted members of the Democratic establishment are accepting that inescapable logic.

The boiled-down modern history of health politics in America is one of liberals slowly slinking rightward, making a hopeless series of concessions in an effort to win conservative buy-in for any system that would cover nearly everyone.

As originally envisioned, Medicare was to cover the entire population, but as actually enacted, it only covered people 65 and over. Conservatives rejected single-payer, but claimed to support proposals that looked an awful lot like Clintoncare. When Clintoncare was actually on the table in the 1990s, conservatives rejected it, and countered with a proposal that looked an awful lot like Obamacare. When Obamacare was on the table Republicans engaged in a massive resistance campaign first to stop it from becoming law, then to attack the law legally, and now to undermine it administratively.

Republicans may have imagined that by boycotting Obamacare, and then by trying to break it, liberals would once again seek detente by negotiating away some of the money and regulations that made the health care law viable.

But the reliable old strategy of holding out for less isn’t working now, and in many ways can’t work, because the ACA, as a construct, is the most attenuated model of universal health insurance policy experts can theoretically devise. By rejecting it in principle, Republicans gave liberals nowhere to go but left.

The ACA works by subsidizing regulated health plans for people who don’t qualify for employer sponsored insurance or a different public system, but the subsidies and regulations are ultimately means of realizing a coverage guarantee, built into the law, that is meant to make it possible for everyone in the country, regardless of income or health status, to obtain decent insurance.

In practice the law doesn’t quite accomplish that goal, but it did effectively end the public debate over whether everyone should be insured. Even in their half-baked efforts to repeal and replace Obamacare, Republicans largely ceded the universality issue. They chose instead to lie about the impact their plans would have on coverage levels, and to include unworkable policy ideas in their bills, as fig leafs to hide their underlying indifference to the plight of the uninsured.

The coverage guarantee is the locus around which any future health reforms will have to grow, but to protect the guarantee, the benefits themselves will have to be less vulnerable to sabotage—more uniform, more public, more universal. It took decades of bad faith negotiations for Democrats to accept that Republicans will never join the global health care consensus. Protecting and building upon the gains of Obamacare will require forging ahead without them.