Single-Payer from the Bottom Up Single-Payer from the Bottom Up What Medicare for All advocates can learn from the fight for single-payer in New York. Members of the Democratic Socialists of America and others join a march for Medicare for All in Los Angeles, February 2017 (Molly Adams / Flickr)

If Lindsey Graham is to be believed, the choice facing American voters is stark. Making the case last week for Senate Republicans’ latest effort to repeal the Affordable Care Act, Graham told Breitbart radio, “It’s either this or . . . full-blown single-payer socialism.”

Thankfully, as of this writing, the Graham-Cassidy bill—perhaps the most extreme yet in a long succession of Republican efforts to reverse Obamacare’s significant, if partial, redistributive achievements—seems poised for failure. The defection of John McCain has left the bills’ sponsors scrambling for key swing votes, even resorting to thinly veiled bribery in a last-ditch effort to save a last-ditch bill.

So—barring a last-minute change of heart from Senators Susan Collins or Lisa Murkowski—is America on the verge of a “full-blown single-payer” system? Maybe not quite, but thanks in part to Graham and his GOP colleagues, universal coverage is much closer in reach than anyone could have predicted even a year ago.

However perversely, Trump’s election and ensuing Republican efforts to strip millions of coverage have created the greatest opening for universal health care advocates since at least the Truman era. Bernie Sanders’s long-awaited Medicare for All bill, released earlier this month, marks a major step toward this increasingly popular goal. Thanks in part to Sanders’s campaign promises and the criticisms they endured, but more directly to state-level efforts across the country, more Americans than ever yearn for an expanded public health care option. In a July AP survey, a heavy majority of respondents agreed that health care coverage ought to be the responsibility of the federal government. The findings were largely consistent with a Pew Research poll from June, which also found that a slim majority of Democrats favored “a single national insurance system run by the government”; its authors stressed that “the share of Democrats supporting a single national program to provide health insurance has increased 9 percentage points since January and 19 points since 2014.” If a new Harvard-Harris poll is to be believed, support for single-payer has only jumped in the months since, now counting 52 percent of all respondents.

Little by little, Congress has been taking note: John Conyers’s Expanded and Improved Medicare for All Act, which he has introduced in every Congress since 2003, has achieved a record 119 cosponsors so far this year (all Democrats). Sanders’s Senate bill, too, was introduced with an impressive sixteen Democratic cosponsors, including liberal favorites Al Franken, Kamala Harris, and Cory Booker (until recently seen as a darling of the pharmaceutical industry). Like Conyers’s bill, Sanders’s stands no chance of passing in a Republican Congress, and neither yet has the support of minority leaders Chuck Schumer and Nancy Pelosi, despite Schumer describing single-payer as “on the table” earlier this summer.

Still, the health care debate has clearly reached an inflection point. The Affordable Care Act has a half-life, it seems, and both the left and the right must contend with its decay. If establishment Democrats are to secure the benefits of the ACA in the present—let alone achieve its underlying goal of extending health care to all Americans—they must clearly do more than hope for another conservative misfire. It is incumbent on Democrats today to take the offensive.

So what will it take to transform Medicare for All from a distancing device against a flailing GOP into a winning policy platform?

The short answer is: a massive popular upsurge, dwarfing even the efforts to preserve Obamacare. Fortunately, several state-level campaigns have already laid the groundwork for such a movement. From coast to coast, grassroots organizers have been hard at work advancing health care expansion on their own terms, rather than relying on partisan ebb.

One good place to look is the New York Health Act, a measure that would abolish private health care and establish single-payer coverage in the state. In May, the majority-Democratic state assembly easily passed its version of the bill, introduced by Richard Gottfried, for the third year in a row. While the senate version stalled—remaining just one vote short of a majority when the legislative session expired in June—the fight for single-payer in New York offers valuable lessons for building a transformative coalition around care. By framing health care access as both a moral imperative and a tool for dismantling an array of inequities based on race, gender, and geography, local advocates have worked alongside elected officials in one of the most promising campaigns for state-level universal care in recent memory.

Gustavo Rivera, the bill’s main state senate sponsor, started out with twenty-one cosponsors in 2016. Through in-person meetings and the work of “senior, child, and disability advocates”—not to mention labor unions like the New York State Nurses Association—nine more senators signed onto the bill before the session ended. They were won over not only by pragmatism but also the moral appeal of the single-payer cause. “I start at this from an ideological perspective,” Rivera said in a phone interview. “I start from the idea that your wealth should not determine your health.” A progressive Democrat endorsed by New York’s Working Families Party, he also believes in nationwide single-payer health care. But state-level policies can inspire or bolster national ones, Rivera argues. To him, state legislatures are “laboratories of democracy,” where the viability of radical ideas can be tested.

Some liberals in his chamber did not take to this approach. Rivera explained: “I start there,” from the ideological commitment to health care as a right, “and many of my colleagues start at the same place, but they have concerns about cost.” Within Rivera’s party, many of those cost-skeptical senators belonged to the Republican-aligned Independent Democratic Conference—the outcome of a bizarre power-sharing agreement that leaves the legislature skewing disproportionately conservative.

Rivera’s colleagues are not alone. Both nationally and at the state level, many would-be supporters of universal health care have gotten hung up on concerns about its cost. In June, after a single-payer bill passed California’s state senate, the Washington Post editorial board dismissed the policy on the grounds of its “astonishing” price tag. “Democrats’ single-payer health-care dream just became a nightmare,” read a CNBC headline evaluating a state senate study on the costs of the California program. Commentators including Cornell economist Robert H. Frank and left-wing policy analyst Matt Bruenig have convincingly parried these claims, pointing out that the seemingly high price tags of single-payer policies pale in comparison to current health care expenditures.

Back in New York, Rivera takes some credit for winning over several of his colleagues on similar grounds. He relied on economic research like a 2015 report by Gerald Friedman of the University of Massachusetts, Amherst, which projected large-scale cost savings for consumers and businesses if the New York Health Act passed—mostly from reduced administrative costs and the monopoly purchasing power the state would acquire on primary care and pharmaceuticals. This is much the same economic rationale Bernie Sanders has cited in defense of his own national plan, and has essentially remained the same for decades. Gottfried, who has served in the New York assembly since 1970, and chaired its health committee since 1987, cites the scholarship of health economist (and Dissent contributor) Rashi Fein, as well as the work of physicians David Himmelstein and Steffie Woolhandler, as early indications of single-payer’s viability. Yet in his view the unification of the mainstream New York Democrats and members of the IDC took more than just individual persuasion. “The expanded public and labor support for [the bill] was probably the major factor that brought them all on board together,” he said in a phone interview.

According to the assemblyman, New York’s lawmakers began seriously considering statewide single-payer in 1991. Unsurprisingly, Gottfried recalled, the first movers on the act were not politicians, but instead groups like the New York State Nurses Association, Citizen Action, and the Statewide Senior Action Council, who urged him to look beyond the private insurance model. “We spent the next several months putting together a draft for the bill, and it was introduced in 1992,” Gottfried said. According to him, that year saw renewed interest in the idea of universal health care coverage. Fueled by Harris Wofford’s Senate campaign in Pennsylvania and the Clinton administration’s early health plan—both of which gestured to universal coverage—the bill passed that spring in the assembly by a margin of about two to one. Despite its initial success, however, the bill failed to make it past the chamber’s ways and means committee every subsequent session until 2015.

This was more a matter of time and energy than ideological conviction, in Gottfried’s view, as lobbying groups diverted their attention to other ventures. The Clinton health plan in the mid-1990s, Medicaid cuts in the late ‘90s, and later the ACA “absorbed the focus” of lawmakers and lobbyists alike. The passage and implementation of Obamacare, he argues, had a chilling effect on discussion around single-payer. “People didn’t want to suggest out loud that the ACA had shortcomings,” said Gottfried. “Once the ACA was implemented in New York, support for the single-payer bill began to grow again.” The NYHA’s current list of endorsers, spanning from Make the Road NY to Housing Works to the Coalition of Black Trade Unionists—Buffalo, bespeaks the overwhelming diversity of support the bill enjoys.

The labor movement in particular gained a new stake in universal health care coverage after the passage of the ACA, as the act began to undermine collectively bargained health plans. Union members enrolled in such plans were ineligible for the health care exchanges and their associated subsidies, as well as susceptible to the so-called “Cadillac Tax”— an excise tax on high-cost health care plans with low cost-sharing requirements (like copays and deductibles). This is likely one reason that union support for single-payer has swelled since Obamacare came into effect, with major New York locals like SEIU 1199 and 32BJ, New York State United Teachers, RWDSU, and Communication Workers of America District 1 signing on since 2014. It was no coincidence, then, that the bill finally reached the assembly floor in 2015 and passed by an almost identical margin as it did in 1992. The Sanders campaign and resistance to Trump have since heightened the chorus. State senator Rivera agreed that the bill’s unprecedented success this year was a symptom of anti-Trump resistance. The “silver lining” of the general election, he argued, was that it forced many people to wake up to political developments not only at the national level but also closer to home.

Crucially, the coalition built support across the state; Gottfried is “constantly delighted” by independent town advocacy groups in west and upstate New York that continue to crop up. The fight for universal health care has also been unique in the way it has brought together career-long Democrats like Gottfried, established labor and advocacy groups, and activists of the resurgent socialist left. Eljeer Hawkins, a Manhattan-based surgical technologist and veteran organizer for Socialist Alternative, sees the NYHA as the first step towards a more radically transformed health care industry. Hawkins imagines “a health care system that was nationalized, that was underneath democratic control—of working people, of doctors, of patients, of health care workers,” that could “keep costs down so ordinary people could have access to it without breaking the bank.” His vision of single-payer, closer to Britain’s National Health Service than the U.S. Medicare system, reflects a broader anticapitalist critique that finds the profit motivation of insurance companies at odds with human need.

Despite its sweeping ambitions, however, Hawkins’s organizing takes aim at specific and familiar issues of health inequity. Reproductive rights, hospital access “in poor, black and brown neighborhoods,” and the opioid crisis are just some of the issues a publicly accountable industry could address in what Hawkins calls a “Marshall Plan” for health care. During the state senate session in New York, members of Socialist Alternative, the Green Party, and the Democratic Socialists of America (DSA) together occupied the office of Simcha Felder—the lone Democrat in the chamber opposed to the NYHA. While Felder declined to support the bill come June, the occupation illustrated how direct-action tactics can complement more traditional lobbying and advocacy. Similar occupations were instrumental in blocking the ACA’s repeal in July: civil disobedience by disability-rights activists outside of Mitch McConnell’s office in Washington, union rallies, and a concerted disruption of the repeal vote itself were key in registering popular outrage at the GOP’s repeal efforts.

For Erin Neff, founder of New York City DSA’s socialist-feminist working group, the fight for universal health care is inseparable from the fight against patriarchy. “The NYHA is a deeply feminist issue,” she explains, because the legislation would “allow women, particularly low-income women, [to be] more independent.” Women are “often dependent on their spouses’ health care” under the current system, Neff says, leaving many to face the perverse choice between being abused or being uninsured. Moreover, she points out, the NYHA would cover abortions. Single-payer could also cover hormonal therapy, sexual reassignment surgery, and sexual health services—which are already covered by Medicaid in New York—for the benefit of transgender and queer people across the state. “You’re more likely to come up against discrimination when you have private insurance companies,” Neff points out, because they’re not accountable to the people in the same way a single-payer program would be.”

“It’s really important that women and gender-nonconforming individuals and trans individuals are leading the charges on big issues” like the NYHA, adds Neff. (It’s worth noting that only a quarter of New York’s state legislators are women.) DSA’s socialist-feminist working group has established coalition-building, field, and political education committees for the NYHA. Its online campaigns, including a Healthcare Humpday in late April, pressured New Yorkers to urge Felder and Kemp Hannon, the chair of the state senate’s health committee, to bring the act to the floor. NYC-DSA also helped add signatures to the Campaign for New York Health’s online petition to pass the NYHA in the senate. DSA’s coordination with the Campaign, the largest single-payer coalition group in New York, has also involved statewide canvassing training and organizing, as well as distributing materials like the Health Care Rights and Access Survey.

Despite these efforts and a renewed sense of momentum, however, the single-payer cause is in store for a challenging year in 2018. Even if the Graham-Cassidy Bill fails—and it is critical that it does—Senate Republicans will likely continue their vicious efforts to repeal and hobble the ACA as long as they hold a congressional majority. It goes without saying, too, that the more Medicare for All gains steam, the more the insurance and pharmaceutical industries will ramp up their own bitter counterattacks.

The legacy of other state-level single-payer bills, moreover, suggests that even in a resolutely blue state like New York, universal health care still faces an uphill battle. The NYHA is the latest in a series of proposals spanning a variety of liberal states that have succumbed to conservative pressures. The speaker of California’s state assembly prohibited his chamber from voting on the Healthy California Act this year, citing cost as the main factor. Vermont governor Peter Shumlin abandoned his own state’s single-payer proposal, which called for a hike in payroll taxes, after a close election in 2014. “Sticker shock” has doomed more than one near-victory.

If states like New York—which cannot run a budgetary deficit in the same way the federal government can—are to break this inertia, health care activists must do more than agitate on the basis of moral appeal. Effective campaigns must take seriously the minutiae of the budgets in their states. In California’s case, health care advocates shared some culpability with the right for the death of their own bill. As David Dayen argued in The Intercept this summer, a failure to account for state budget capping, obligatory earmarking for education, and the necessity of calling a ballot measure sunk Healthy California as much as party politics did, rendering its campaign little more than a virtue signal for ambitious liberal politicians.

The stakes are high. Just as Obamacare rose from Romneycare in Massachusetts, and Canadian health insurance emerged from provincial policies, state-level single-payer could serve as proof-of-concept for a national policy. Yet a national spotlight cuts both ways. If the NYHA passed and failed, it would make a national analog all the more unlikely—not to mention the fallout at the state level.

Still, single-payer advocates are at a unique juncture, and there is no better time for allies across the broad liberal-left to seize it. National campaigns like Medicare for All can provide resources, visibility, and a morale boost to grassroots movements for state-level reforms. Establishment Democrats, too, could learn from local single-payer advocates in New York—especially radicals like Neff and Hawkins—who see the implementation of a single-payer system as a vital step in confronting broader ills like patriarchy and institutionalized racism. Ultimately, the fight for single-payer must enlist pragmatic strategy for moral ends—not the other way around. And that means lawmakers should look not among themselves, but below, for how to carry the fight forward.

Martin Ridge is a writer and student currently based in London. He is also a former Dissent intern whose writing has appeared in the blog of the Journal of the History of Ideas.