On an early morning conference call on Friday, I heard the circular logic being used in high level political circles to effectively block any progress beyond the Affordable Care Act. Many elected officials in the United States are playing political games with next steps for advancing health reform as they either wait to see Obamacare be successful or they pray for it to fail. No surprises in this, eh? DC has come to almost incapacitating halt in terms of meaningful policy and/or law-making in recent years, and this has been well-reported and documented.

In terms of the ability to advance single-payer, improved and expanded Medicare for all reforms, the cycle has gone something like this for the past five or six years (not a comprehensive review):

2008—As the Obama-McCain presidential campaign moves forward, Obama says health care is a right, and McCain says it's not. Obama promises to take action immediately when elected, and also relays rather clearly that single-payer might have been the way to go if "we were starting from scratch." Meanwhile, back in DC, Max Baucus' Senate Finance Committee is already drafting the white paper that will serve as the template for a very insurance-industry-friendly health reform effort.

2009—As promised, Obama launches into the push for health reform, ala a Massachusetts-like, Romneycare model (as drafted by former insurance industry insiders like Liz Fowler and vetted by America's Health Insurance Plans—AHIP—and its spokesperson, Karen Ignagni). In the summer months, the Tea Party folks go insane at Congressional town hall meetings and paint the insurance industry written bill, The Patient Protection and Affordable Care Act (ACA/Obamacare) as a government takeover of health care. even staunch single-payer advocates in Congress tone down their single-payer advocacy as they help the Dems push the ACA. Many, if not most, promise to get back to single-payer work after the ACA has been passed.

2010—ACA/Obamacare passes after many contentious months of debate. At its core is very friendly, the very pro-industry insurance purchase mandate that was also the core of Romneycare in Massachusetts. It passes with a provision, Section 1332, that will allow states to innovate in 2017 if states can show their plans to be as or more comprehensive, affordable and cover more people. Because the political pressures are still high, many of the single-payer folks who promised to get back to work on single-payer want to hold off until after the 2010 mid-term elections because they don't want to lose their Congressional majority. They hang together but lose the Congressional majority anyway.

2011—Sen. Bernie Sanders and Rep. Jim McDermott re-introduce their single-payer bills, title the American Health Security Act of 2011, and Rep. John Conyers also re-introduces his single-payer bill, HR676, on the House side. Co-sponsorship of the bills not nearly as strong as many begin to take a "wait and see" posture in anticipation of the beginning push for implementation of the ACA. No one who worked on the ACA wishes to be seen as saying much negative about the bill they helped craft and pass.

2012—Here comes another election year, but this one is also a presidential election. Most politicians want to distance themselves from any mention of single-payer effort at all and certainly from tying any of the ACA reforms to any relationship to single-payer. States begin wrestling with the issues of Medicaid expansion, etc. Many states have groups working on single-payer, state based effort—notably Vermont has passed Green Mountain Care -- a road map to getting their state to a single-payer system. But, again, politicians stay clear of really fighting for single-payer for two reasons in 2012: first in advance of the Supreme Court ruling on the insurance mandates and then as they worry any single-payer support may be interpreted as a negative commentary on the ACA during the election cycle.

2013—Now single-payer cannot be supported by many, if not most, national politicians because in the early enrollment phases approaching for the ACA's state insurance exchanges, politicians who worked on the ACA don't want to rock the boat and in any way diminish the chances for ACA success. So, though we have a brief reprieve from election season (not really a reprieve at all), no one will take a very strong pro-single-payer stand.

So, what would we expect in 2014? Oh, that will be an election year. Then 2015? that will be a pre-presidential-election year. 2016? An on and on and on. Similar pressures happen at the state level as state politicians hedge their political bets too as related to ACA success or failure. I have seen and felt first hand the wrath of single-payer politicians who when pressured sometimes act quite inappropriately toward those harmed by the health care system in favor of protecting their own political standing. DC does not hold the corner on this kind of lousy political behavior.

Those of us who want to see single-payer, improved and expanded Medicare for all for life, advance, will need to stop pinning our hopes on political action on the national level and be wise about how we use these politicians when they need us to support them during election cycles. We're going to have to turn the way we have pursued this work into a transformative movement led by the people most damaged and most invested in having a secure, humane and economically just health care system.

Our health care dead cannot speak for themselves, but our health care system broke and damaged certainly can. Our movement for single-payer will have to raise these people up instead of relying on traditional top-down movement leaders or intellectuals and speak real truth to one another about just how corrupt the health care system has become in America. And it isn't just the insurance companies by any means who hold the corner on greed and abuse of their corporate power over human life.

I hope to look more closely at this corruption in the weeks and months ahead, and I hope to write honestly about it. Some of our political trouble comes from the fact that the people killed and hurt by our greedy health care system are told they are cared about by some of the same people who behind the scenes are strengthening the ugly, corrupt systems that bleed us dry. We will see single-payer prevail. But it will be because we change the movement and change the dynamic at play in the backgrounds of the halls of power in DC, in state houses of government, and even in some of the advocacy community as it has functioned in the recent past. We will fight until we win because the dead and the broke won't stop adding up.

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Donna Smith, American SiCKO



About author Donna Smith is a community organizer for the Donna Smith is a community organizer for the California Nurses Association and National Co-Chair for the Progressive Democrats of America Healthcare Not Warfare campaign