Barack Obama dropped a bombshell into the healthcare debate roiling the Democratic party last Friday. “Democrats aren’t just running on good old ideas like a higher minimum wage,” he said, “they’re running on good new ideas, like Medicare for All …” His endorsement made headlines, and for a good reason: until recently, real universal healthcare had long resided on the margins of the American political discourse. Obama’s announcement, then, was yet one more indication that this idea – also called single-payer healthcare – had migrated to the mainstream. The shift is an encouraging development for proponents, to be sure, but there is also cause for caution: as history shows, formidable political obstacles and pitfalls lie ahead.

It is difficult to overstate how far single-payer has recently moved. Consider, for a moment, where things stood after Democrats took the presidency and both houses of Congress in 2008. “The White House and Democratic leaders have made clear,” the Washington Post reported the following year, “there is no chance that Congress will adopt a single-payer approach … because it is too radical a change.” Single-payer supporters didn’t even have a seat at the table (and some were arrested when they showed up anyway).

Following the passage of the Affordable Care Act, however, several developments pushed single-payer to the fore. First, although Obamacare expanded coverage to some 20 million people – achieving much good – it raised hopes that universal healthcare would be achieved while failing to deliver it: some 29 million remain uninsured today, while many more face onerous deductibles, restrictive insurance networks, surprise bills, unaffordable medications, medical bankruptcies and disruptions in care with every change in insurance plan.

Next, there was the 2016 election of Donald Trump, which made it obvious that Republicans lacked even a semi-serious alternative. Congressman Paul Ryan’s long-awaited ACA repeal bill was mostly a mechanism to transfer healthcare dollars from the poor into the savings accounts of the rich, and it seemed to satisfy no one except for wealthy donors.

Finally, there was a marked progressive shift within the Democratic party, beginning with the 2015-16 presidential primary campaign. Former secretary of state Hillary Clinton opposed single-payer, saying it would “never, ever” happen, but it was central to the platform of Vermont senator Bernie Sanders. Sanders lost the primary, of course, but he advocated better ideas.

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Obama’s endorsement of single-payer on Friday (despite having previously said something similar) is therefore tantamount to a major shift in the Overton window, reflecting years of activism by single-payer supporters as well as a historic intra-party shift.

Today, in primary contests across the country, progressive Medicare-for-All proponents are ousting more centrist and establishment candidates – Alexandria Ocasio-Cortez’s surprise primary win in New York’s 14th congressional district being the most popular example. At the same time, public support has soared: a recent Reuters poll found that 70.1% want Medicare for All, including 84.5% of Democrats. One might even argue that for people who want a job as a Democratic politician, in other words, supporting single-payer is nearly becoming a prerequisite.

None of this is to say, however, that enacting it legislatively – even with a new government in power – will be easy. We have, after all, been down this road before.

A concept older than Medicare

As some have noted, Obama wasn’t quite right to call Medicare for All a “new” idea: on the contrary, Medicare for All is a concept older than Medicare itself. Medicare came about after the defeat of single-payer – then called “national health insurance”– during the Truman administration. The campaign against it was led by the American Medical Association (AMA), which famously did it in with the help of a cutting-edge public relations firm that waged an unremitting campaign of cutthroat red baiting (drug firms also lent support).

But something similar is brewing today. As the Hill reported last month, a new anti-single-payer group has recently formed – drawing together the lobbying muscle of both insurance companies and big pharma – and it’s spoiling for a fight. Single-payer poses an existential threat to insurers, after all, and the industry’s coming PR blitz could make the famed “Harry and Louise” TV ad campaign of the 1990s – credited with helping sink Bill Clinton’s healthcare reform –look like an undergraduate’s mediocre final project for a marketing course.

This is a major obstacle, but a surmountable one: all great reforms in history, including Medicare itself, had to overcome powerful opponents. Yet a second potential pitfall lies ahead: despite all that has happened, politicians could still walk away from single-payer – probably by watering “improved Medicare for All” down into something unrecognizable. And again, something similar has happened before.

After the AMA’s defeat of national health insurance, its architects narrowed their proposal to cover just seniors; this became known as “Medicare”. However, the idea was that the Medicare approach could later be used to cover everyone. A push was made to realize this universal vision within a few years of the implementation of the program, and indeed, had things happened somewhat differently, some sort of national health insurance legislation could have been achieved in the 1970s.

Ultimately, however, the movement disintegrated – in large part the consequence of a historic rightward political turn that culminated in the election of Ronald Reagan. Fatefully, this was also the moment when the Democratic party abandoned national health insurance, instead embracing a private-insurance based alternative built on Richard Nixon’s reform proposal, which the ethically compromised Republican president had offered as a counter to single-payer.

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Brick-by-brick, the campaign for national health insurance was rebuilt. In the late 1980s, for instance, the organization I serve – Physicians for a National Health Program – was formed, and its proposal for what was newly called “single-payer” became the blueprint for HR 676, the Improved and Expanded Medicare for All Act that was first introduced in Congress in 2003. That year, it had only 38 co-sponsors, but today HR 676 is supported by an unprecedented 123 lawmakers, or some two-thirds of the Democratic caucus. Meanwhile, Bernie Sanders’ companion bill in the Senate, the Medicare for All Act of 2017, has achieved 16 co-sponsors (his previous bills had zero).

The future of single-payer

The danger, however, is that even with the prospects of these bills on the rise, Democrats could turn away from the essence of the vision. Already, some are aiming to mutate Medicare for All into something vastly inferior – for instance, into an expansive “public option”-type program that would retain a major role for private insurers (eg the Center for American Progress’s confusingly labelled “Medicare Extra-for-All”). But to achieve real universal healthcare, Democrats can’t afford to repeat the mistakes of the past and flee to a private-insurance based reform a second time around. Medicare for All must remain what it is today – how it is detailed in a bill like HR 676 – if it is to mean anything at all: fully public national health insurance providing comprehensive, universal coverage to the entire nation.

Wilbur Cohen, a chief architect of both Truman-era national health insurance and Medicare, recognized this when he asserted that private insurance companies should have no role in a Medicare for All system, although it was not yet called that. “[O]nce the Federal Government decides that everybody is going to be insured,” he put it in 1977, “there is no need for a private insurance company to go out and sell coverage … using private insurance agencies to achieve the public responsibility seems to me to be wasteful and unnecessary, imposing an additional cost … without any essential advantage.”

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His point is even more salient today: private insurance companies add only fragmentation and cost, something we can’t afford as we work to provide everyone in the nation with comprehensive first-dollar coverage.

For the first time in a generation, the realization of a right to healthcare – through implementation of a single-payer system – is on the horizon. But achieving it requires not repeating the mistakes of history. It means somehow countering a staggeringly rich corporate opposition while at the same time preserving the essence and the details of the vision – one which, by necessity, leaves no room for the waste and avarice of the private insurance industry. It is a formidable task, but one that has never seemed so winnable.