WASHINGTON—They called him a killer. They played dead in the street.

Tom MacArthur was the Republican congressman who revived Donald Trump’s unpopular plan to replace Obamacare. He came home to liberal rage.

When MacArthur held a town hall in his New Jersey district last month, activists lay outside holding mock tombstones. Inside, other constituents subjected him to story after story about how Obamacare has helped their families.

And, also, a chant that was not about Obamacare at all.

“Single-payer! Single-payer! Single-payer!”

Democrats are waging a furious battle to preserve the health-care gains achieved by Barack Obama’s reforms. But many of them are no longer content to stop there.

With the Bernie Sanders left rising in influence and the president backing a plan to deny insurance coverage to millions, an idea that has long seemed a U.S. pipe dream has gained steam with the Democratic base: a single-payer system, more or less like Canada’s, in which government would cover the cost of universal care.

Supporters acknowledge that the chances of single-payer happening anywhere in the U.S. any time soon remain very slim. But there are signs that the politics are shifting on the left — and a little even on the right.

“I think this is going to be potentially one of the biggest changes, ironically, coming out of the Trump administration and Paul Ryan and Mitch McConnell’s Congress. Ironically they may be pushing us far faster to this. It ironically is multiplying our chances,” said Minnesota state Sen. John Marty, who has pushed single-payer for a decade.

California’s Democratic state Senate passed a single-payer bill on Thursday. Democrats are making a similar effort at the New York state house. For the first time, a majority of the Democratic caucus in the federal House has endorsed a bill for national single-payer.

And the party base is fired up, pressing lawmakers around the country about what Sanders calls “Medicare for All.” The energy, some progressives say, suggests that support for single-payer could evolve a litmus test for future Democratic presidential candidates.

“Just like marriage equality went from an issue where very few national Democrats were supporting it to an issue that every national Democratic candidate was expected to support: I think you see a transition, and I think we’re seeing that with single-payer,” said California state Sen. Scott Wiener, a co-author of the bill there.

Trump’s plan, passed by the House after MacArthur wrote a key amendment, would leave 23 million fewer people with insurance in 2026, experts estimate. The knowledge that Obamacare’s gains are precarious “has pushed more people into thinking, ‘Well, let’s get it for everyone and make sure it can’t be taken away,’ ” said Maura Collinsgru of liberal group New Jersey Citizen Action.

“Because if the alternatives are national health insurance versus ‘if you can’t afford it you die’ — I think this is waking people up to that,” said retired N.J. doctor Eileen Hill, who founded a chapter of the anti-Trump Indivisible “resistance” movement. “I think it’s made people think about health care a lot more than they have. I think it was a wake-up call to: ‘Oh my God.’ ”

Single-payer would be a massive and messy undertaking anywhere in America. The current system, the world’s most expensive per person, is a hodgepodge of public and private: employer-sponsored insurance for about half the population, government insurance for the poor and elderly, and government-subsidized private insurance for others.

Single-payer takes various forms in different places. Broadly, though, it would replace all of the current kinds of insurance with one government program, like Ontario’s OHIP, and eliminate the need for health payments foreign to most Canadians, like deductibles and co-pays.

Many U.S. experts believe such a switch would reduce both the average person’s health spending and the cost of the overall system, giving the government the bargaining clout to negotiate lower prices. But the politics are difficult even in liberal bastions like California.

Politicians would almost certainly have to vote for hefty tax increases. They would have to address fears about wait times and creeping “socialism.” And they would have to challenge wealthy interest groups who profit from the current structure, including doctors, hospitals, insurers and drug companies.

“The real obstacle to a true single-payer system in America is not politics, in the sense of voters, Republicans blocking such a bill. It’s doctors and hospitals who would stand to be paid a lot less money,” said Avik Roy, who has advised Mitt Romney and other Republican candidates on health policy.

Single-payer faces great skepticism among powerful elected Democrats. House minority leader Nancy Pelosi said in May that the party should not run on single-payer in 2018, explaining that “the comfort level with a broader base of the American people is not there yet.”

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Conservative analysts are among those who see views changing. On Fox News in March, pundit Charles Krauthammer predicted that Trump-era Republican politicians would inadvertently produce national single-payer within seven years. And Roy noted that Trump’s own rhetoric has altered the terms of the Republican discussion.

Trump praised single-payer in a Republican primary debate, saying “it works in Canada, it works incredibly well in Scotland.” Though he stopped making such claims, he continued to argue for covering “everybody” — a radical departure from the usual Republican talk of freedom, choice and small government.

“The arguments for universal coverage are getting increasing traction in the right-of-centre world, and Donald Trump actually has a fair amount to do with it,” Roy said. While he advocates a market-based approach to achieving universal coverage, he said “almost anything is an improvement on the American health-care system.”

“There are certain ways, particularly on the cost side, where a federal single-payer system would be an improvement on the health-care system we have now. But where a single-payer system really suffers is the lack of choice and competition,” he said.

The polling on single-payer is ambiguous, varying wildly depending on how the question is framed. One in April found that 43 per cent of Republicans supported “creating a federally funded health insurance system that covered every American,” against 44 per cent opposed. But when pollsters actually use the phrase single-payer or mention a tax increase, support tends to plummet into the territory of political disaster.

The California effort appears likely to fail. Though the state Senate approved the bill, legislators have not figured out how to raise the required additional revenue — an eye-popping $200 billion per year.

Democratic Gov. Jerry Brown has expressed strong reservations. And the state would have to somehow obtain approval from Trump to transfer federal funding to the new system.

California’s bill is so expensive, in part, because it would be far more generous than Canada’s system, fully covering dental care and prescription drugs for everyone including illegal immigrants. William Hsiao, an economist and single-payer expert at the Harvard School of Public Health, lamented that U.S. plans are letting “the perfect become the enemy of the good.”

Hsiao helped design the most advanced recent drive for single-payer, in Sanders’s state of Vermont, which collapsed in 2014 when the Democratic governor decided he could not tolerate the required tax hikes: 11.5 per cent on employer payrolls, up to 10 per cent on individual incomes.

The hikes were so big, Hsiao said, because Democrats insisted on a version of single-payer that covered far more costs than he recommended.

“I explained to them that would not be politically wise and feasible,” Hsiao said. “And explained to them you should go for what’s good, and then, if you think you have the political influence later on, you can expand the benefit package.”

Restraint is an even harder sell today. The Democratic base of the Trump age is in no mood for anything that smells of a half-measure.

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