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Medicare for All Is a Strategy

Medicare for All is not just about fixing our broken health-care system. It’s about unlocking the power of a mass, working-class movement in the United States.

Demonstrators at a Medicare for All rally in Los Angeles in February 2017. Molly Adams / flickr

We won’t rehearse the familiar points about Medicare for All: it’s good, it’s needed, it’s what the people want — as Fox News recently found out the hard way.

But Medicare for All is more than just a matter of fixing our broken health-care system. And it’s more than just a good policy. It’s the perfect fight to pick with our ruling class — one that can unlock the power of a mass, working-class movement in the United States.

We don’t believe this because we think health care is somehow naturally more important than other issues. On moral grounds, it’s hard to find an injustice more tragic than migrant detention camps, and we could be convinced that any number of causes are more morally urgent than Medicare for All. On scientific grounds, the imminent threat of climate disaster is surely the most pressing issue, not just for the Left but for humanity as a whole. But on political grounds, if we want to take the nascent left renaissance in America and turn it into a durable, working-class movement in the 2020s — a precondition for addressing more morally and more scientifically urgent issues of the day — the fight for Medicare for All must be at the very top of the Left’s priorities.

Despite modest growth in the wake of Bernie Sanders’s 2016 primary run, the American left is still near a historical nadir in terms of its political power and, not uncoincidentally, in relative isolation from the working-class people, institutions, and culture it would need to win real power and influence on the national political stage. Forget our ambivalence about class centrality: what really matters right now is our lack of class rootedness.

The central question at present must be: How do we anchor our politics in the lives of working people and institutions? The unmoored left does not get to decide what issues should be prioritized based on its own determination of moral or objective exigency. Rather, we must construct our strategy on the basis of a political analysis of the contemporary situation, considering first and foremost what will attract millions of people to the American left in a concrete and material way. And for that, we believe that there is no better fight than the one for Medicare for All.

Medicare for All Will Work

It’s easy to lose sight of this simple fact when embroiled in the myriad and complicated debates that exist on the Left, but most people won’t be attracted to left politics just because we have the correct political positions or out of an abstract commitment to justice. The best means of expanding our ranks from the thousands to the millions is by demonstrating that not only does socialist policy work, but that it very rapidly makes a lot of people’s lives noticeably better.

For starters, we can count on the 30 million people today who have no insurance whatsoever to be big fans of Medicare for All. The 57 million people between nineteen and sixty-four years old who are underinsured — those who have “insurance” but are just as likely to skip a doctor’s visit as the uninsured because of their insurance plan’s crippling cost-sharing measures — will also benefit from being able to seek medical care for themselves and their children without fear of financial ruin. Seniors will get their Medicare coverage expanded and keep the 40 percent of their Social Security benefits that they currently have to spend on health-care costs. But most important, in exchange for a slight bump in their taxes, everyone who currently gets their health care through their employers (the majority of the population) will likely receive a substantial boost in their paychecks, as well as a huge decrease in their out-of-pocket medical expenses. It’s estimated that a middle-income family would trade the $10,000 per year they’re currently spending on health-care costs for a mere $900 tax increase.

Once in place, a Medicare for All system will be all the evidence we need to convince millions of people in America that democratic socialist politics is not only possible but also materially beneficial. If you think Medicare for All is wildly popular now, just wait until it actually exists.

This is not to say there will not be problems: if the rollout of the Obamacare exchanges was any indication, there will likely be many technical problems involved in the creation of a new government program. In addition, it is certainly possible that the excellent bills currently in the House and Senate (H.R. 1384 and S. 1129) will be watered down in certain ways, perhaps by eliminating the costly coverage of long-term care or introducing some cost-sharing measures. And though our enemies are unlikely to have the political will to undermine and underfund the new system at the moment of its creation — since too many players will have a stake in its success — every socialized program can be slowly whittled down to dysfunction by conservatives over time, as illustrated in the NHS’s recent rationing program. (It should be noted, though, that the NHS is still very popular with the British public.) In all these ways, Medicare for All might not be everything we want it to be.

But here’s the thing: given the truly epic irrationality of the current health-care system, even a less than ideal single-payer system is likely to be a massive political success. This is one of the specific “circumstances existing already” under which we must understand Medicare for All to “make history”: no other industrialized country’s economy is being bled dry by health-care costs in the same way as the United States’, and even an imperfect Medicare for All, by attacking the root of the problem (for-profit health insurance), is going to be remarkably successful for a remarkably high percentage of people. If single-payer health care was met with mass approval in other countries in the postwar period, for an American today, it’ll be like stumbling upon an oasis in the desert.

Medicare for All Will Lead to a Mass Politicization

As far as “non-reformist” or “transformative” reforms go, Medicare for All is the closest the American left has to a sure thing. We’ve seen it work elsewhere, and the historical brokenness of the American health-care system perversely assures its success and subsequent popularity.

Compare this, for a moment, with another transformative demand that has captured the attention of the Left: the Green New Deal. Though Medicare for All and the Green New Deal are often mentioned in the same breath as key planks of a democratic socialist platform, they are in fact quite different in several key respects. While the Green New Deal is a relatively new and expansive set of related policy proposals (sometimes including Medicare for All) and thus far mostly aspirational, Medicare for All is a specific policy that exists in the form of excellent pieces of comprehensive legislation, including a House bill that is now cosponsored by a majority of Democratic representatives (more on this in a moment).

But more important for our present purpose, the Green New Deal, as opposed to Medicare for All, is going to require massive state experimentation, including investing in some programs that could well be huge flops. This is perfectly fine — in fact, it’s what the state should be doing — and some failures must be expected. After all, humans have never averted anthropogenic climate disaster before. Climate scientists know what we need to do in terms of decarbonization, but no one can know ahead of time the exact blend of policies and programs that will get us there.

Heterodox economists sometimes think that once we reimagine the state, it can just do the dynamic and “entrepreneurial” things they want it to. But they forget that state experimentation must be supported, or at least tolerated, by the electorate. Where are we going to get the political will to accomplish something as far-ranging and experimental as the Green New Deal? It bears repeating: people will be won to left policies if we can show that they make their lives noticeably better. A dramatic win like Medicare for All would establish the trust and durable support — support reinforced on a daily basis in concrete, material ways — of millions of people, which would give us the credibility to move forward with riskier but nonetheless extremely urgent and necessary reforms.

In other words, the surest path to a Green New Deal runs through Medicare for All.

To be clear, Medicare for All will not by itself lead to an efflorescence of political participation; in fact, as a program that operates most efficiently when centralized on the largest scale possible, Medicare for All does not, by definition, offer opportunities for local community building and engagement. But we are not currently suffering from a lack of opportunities for political participation. What we are suffering from is a broader political malaise, where most people remain unconvinced that “politics” signifies anything more than tawdry posturing in an arena distant from their everyday lives.

Medicare for All will change their minds, and not in the abstract: it will demonstrate that politics can be about me, my family, and my friends, but without being a zero-sum game. It will open the door to a broader transformation of society and keep that door propped open with near daily reminders of why democratic socialist politics is in the direct self-interest of the vast majority of people.

Medicare for All Crystallizes the Divide Within the Democratic Party

Thus far, we have focused on what will happen if we win Medicare for All, which would involve nothing less than a decisive political sea change in America, again given just how many and how much people will noticeably benefit from the socialization of health insurance. It’s essential to keep in mind that we are working not just for a better health-care system but also for the transformation of politics as we know it. This is not just about “defeating Trumpism,” but about ensuring that the reactionary forces of capital don’t get a whiff of executive power for the foreseeable future.

But while we are still on the path to single-payer, it is also important to be clear about what the fight for Medicare for All can and, in fact, must do along the way: namely, crystallize the divide within the Democratic Party, fracture capitalist class solidarity, and elect Bernie Sanders to the presidency.

On this first point, we have unfortunately encountered much confusion as to what precisely Medicare for All means vis-à-vis the Democratic Party. Many on the Left feel that Medicare for All, since it has become a topic of intense debate within the Democratic Party, has become mainstream — maybe even something we can leave to our Democratic representatives to see to on their own — and thus something we can neglect for more pressing or urgent issues “to the left” of Medicare for All.

It is a frustrating opinion to hear because the fight now, and for the immediate future, is not with the Republicans but with the Democrats, who receive more money from the health-care industry than do their counterparts across the aisle. It is the Democrats in the Senate who have outdone one another in formulating bills that compete with Sanders’s. It is the liberal Center for American Progress that proposed “Medicare Extra for All,” a plan that would create a public option while leaving the private insurance industry intact. It was Obama’s health-care expert Andy Slavitt who created the absurd United States of Care nonprofit, an organization devoted to siphoning away the energy around Medicare for All into “affordable sources of care” with “political and economic viability” — code for a revamped Obamacare that also leaves private insurance alone.

One can see the red (or in this case, blue) thread running through these many proposals, with their dizzying array of policy options: they all preserve the private insurance industry. The Democratic Party is capital’s first and most effective line of defense because it has, since at least the 1970s, spoken the language of the popular classes, captured their votes, and posed as a vehicle for social reform while practically forsaking the interests of the working-class majority.

But while cozying up to their friends in business, every Democratic Party politician claims to care about the health and well-being of their constituents, and this contradiction between their universal desire to appear caring and their support for the for-profit health-care industry should be mercilessly exploited. Making a commitment to Medicare for All into a litmus test, an absolute precondition of any support whatsoever, is the best way to divide Democrats into (at least partially) independent politicians on the one hand and their establishment imitators on the other, the latter of whom must be exposed and publicly embarrassed for their servility to industry sponsors.

We are of the opinion that the Left, while unashamedly using the Democratic ballot line, should be aiming to form an independent, working-class party, and that this duopoly-undermining party is an organizational necessity for the democratic socialist project to succeed. But how do we get from here to there? Organizational independence requires first that the two-party system be broken, and more specifically that the Democratic Party be fractured, so that there is space and opportunity for other organizational forms to develop.

What better way to do this than through a bill that, after the recent flip of Hakeem Jeffries through a well-organized grassroots pressure campaign, has the cosponsorship of precisely 50.6 percent of House Democrats? No other non-reformist reform is so far along in terms of legislative advocacy, communications strategy, and field presence, all of which have combined to win over a slim majority of Democratic representatives. Medicare for All is ideally suited to function as a wedge because there is a roughly equal number of Democrat officials for and against it. It is natural that there will be causes “to its left” (in the weak sense of lacking support from Democrats), but none of those issues carries the force needed to split the party along lines of class allegiance. Medicare for All does.

Medicare for All Fractures Capitalist Class Solidarity

By relieving employers of the responsibility to subsidize (if stingily) their employees’ health insurance, Medicare for All would save a lot of businesses money. This is not an important selling point for the Left, but just as the feigned Democratic Party support of Medicare for All should be a central factor in the formation of socialist strategy, so too is the “business case” for single-payer paradoxically an important reason that it is a strategic issue to prioritize.

As we all know, capitalists practice class solidarity; in simpler terms, they look out for one another. At the personal level, they sit on the same nonprofit boards, their kids go to the same schools, they belong to the same country clubs, etc., and so it’s natural that they would stick by the people they know. But they also do so because at the structural level, they understand the tremendous threat that the successful socialization of one industry poses in pointing to the possible socialization of the next.

The fact that there is a business case for Medicare for All, let alone organizations devoted to popularizing it, does not mean that single-payer is actually in the interest of capital. It means, rather, that it is an issue with which we can get some CEOs to shun their golf buddies in exchange for a few of their own dollars saved. To be clear, we should challenge the business case for Medicare for All at every turn: the reason to get rid of private insurance companies is that they make life worse for most people, not that they affect employers’ bottom line.

But it’s unwise to dismiss what amounts to calls by some capitalists for the elimination of a for-profit industry as irrelevant to socialist analysis. The fact that some have abandoned their time-honored animosity toward social health insurance is not a sign that Medicare for All has become a tamer issue or that capitalists have become more enlightened. It is a sign that the crisis in our health-care system is so massive that even members of the capitalist class are suffering from its irrationality.

In this way, the business case for single-payer exposes the particular vulnerability of the private insurance industry, its place as a weak point in the armor of the capitalist class, and thus its status as a strategic target for the Left. Better still, it just so happens that this point of vulnerability is also a central node of capitalist power. The private insurance industry might be costing businesses in financial terms, but it also gives them important leverage over their employees. By decoupling health insurance and employment, Medicare for All would free workers from a major source of dependence on their bosses, weakening the power of capital across the board. Workers could finally use their bargaining power on things like better wages and working conditions, and could strike without fear of losing their and their dependents’ health care. Institutional labor would also be emboldened to move away from “fortress unionism,” where they defend the past gains of a diminishing membership, and toward becoming an advocate for the entire working class.

Medicare for All and Bernie Sanders

The varied progressive groups in the fight for Medicare for All must quickly get clear about the fact that there is only one presidential candidate who will make Medicare for All the signature issue of his time in office, and that is the candidate who wrote the damn bill.

Every other cosponsor of Bernie’s bill or supporter of Medicare for All has given indications that they will not deliver on the promise of single-payer health care. A day after Kamala Harris proclaimed her readiness to do away with private insurance companies, her advisers signaled that she would “be open to the more moderate health reform plans.” Like Harris, Cory Booker is a cosponsor of S. 1129, but also a cosponsor of six other, more moderate health-care bills in the Senate, in addition to being a top recipient of donations from big pharma. And Elizabeth Warren, while making bold gestures in debate, has left herself plenty of outs. Her recently released Medicare for All financing plan is not only an “unworkable mess,” but also a clear indication that she has no plans to implement Medicare for All any time soon.

All of these candidates “support” Medicare for All because they want to win over the Berniecrats from 2016, but they have all also been pretty clear that they would water it down when the time comes. This is not a sign that they are being “realistic” about Medicare for All’s political viability; it’s a sign that they are caught between wanting the glow of supporting a wildly popular demand and wanting the money of large donors in the health-care industry. The only thing that is not viable here is the notion that we’d get anything more than a push for a glorified public-option bill under a Booker, Harris, or Warren presidency.

We know that Bernie Sanders will fight tooth and nail to make Medicare for All a reality, and perhaps we all haven’t fully appreciated that fact. A leading presidential candidate wants to bring an industry that accounts for almost one-fifth of US GDP under public control, and we’re damn near certain his plan would be a massive success and quickly become immensely popular in a personal and concrete way for 95 percent of people in the United States.

Rather than aiming always to police the progressive boundary of Sanders’s campaign, we believe it is important for the Left to think about how we can use a Bernie Sanders presidency to get what we want. In the first two sections of this article, we laid out the reasons that Medicare for All is uniquely suited to open the door to a broader political transformation in America, decisively undermining the appeal of reactionary conservativism and tired neoliberalism alike. If this broader transformation is what we want, and Medicare for All is the best means available to open an extended window to accomplish it, then full-throated support for Bernie Sanders naturally follows. The reason to support Bernie Sanders is thus not that he has the “right” positions on every issue, but that he bears the commitment and class-struggle mentality to win the kind of transformative reform that would provide the Left with durable political power. At this particular historical juncture, to be on the Left and waffling about Bernie is a contradiction in terms.

As we begin to catch glimpses of the endgame in the fight for single-payer, it’s time to be clear that Medicare for All is more than just a matter of “health justice.” Medicare for All is about carving out room for independent political organization. It’s about hitting our enemies where they’re weak, at a moment when taking advantage of that kind of opportunity is an absolute necessity. It’s about creating the conditions for durable, working-class solidarity and emboldening unions to fight for the working class as a whole. And, most of all, it’s about laying the groundwork for democratic socialist power in America.