It’s a very exciting moment. The ground has shifted. It’s become a unifying issue for the resistance to Trump. People are looking for what they want to fight for rather than just circling the wagons around a pretty crappy status quo on health care.

While unions did an excellent job helping to organize the resistance to Trumpcare, what’s really notable is the outpouring of popular support for Medicare for All that took place at town meetings and similar forums. People are moving on their own to these positions.

When Sanders submitted a bill in 2014, he never got a single cosponsor. Now he has sixteen.

It’s not that the political class has suddenly awakened to the merits of Medicare for All. It’s because they have to go back and face their electorate. They have to face a grassroots movement.

Bernie’s 2014 bill was focused on state-administered health plans. But he found out during his presidential campaign what a powerful response Medicare for All got, and he refocused his bill to make it much more similar to John Conyers’s bill in the House, HR 676.

The power of this new grassroots movement is borne out by the discussions that led to the final drafting of the bill. At one point it appeared that Sanders was incorporating significant cost-sharing through copays, in an attempt to appear more responsible about the financing. But movement organizations reacted aggressively.

Physicians for a National Health Program circulated a letter against cost-sharing. A number of unions quietly weighed in. And the final draft does not include any significant cost-sharing.

Copays are not good from a medical perspective — they discourage people from getting care. And they are not needed to finance a single-payer bill. There is a tendency to bargain against yourself. From an organizing perspective I think we need an aspirational, visionary bill rather than a pre-compromised version.

We’re still in a movement-building moment, though we can win some breakthroughs at the state level. I look at it as you would in an organizing drive. We’re at that moment right before the boss really finds out what’s going on. There’s wide support among the workers, but it hasn’t been tested and the boss hasn’t weighed in yet.

This is the moment when we have to prepare for the counterattack. Figure out who our friends are and build the type of coalitions we need to resist the medical-industrial complex. Do the type of inoculation you would do in an organizing drive. Prepare people for the attacks and arguments the other side will use when they try to discredit us.

There are huge forces that benefit from the current health care system. We can’t have any illusions about what we’re going to face as we move into the endgame of actually winning a referendum or passing a bill.

On the West Coast, California, Washington, and Oregon are all moving in the same direction toward voter initiatives, though it’s too early to tell whether it will happen in a coordinated fashion. They have substantial resources, substantial labor support, and an understanding of what it takes to win initiatives in those states. We need to focus on scaling up our organizing capacity. In California you need something like $100 million and ten thousand door-knockers to run a credible initiative in the face of huge opposition.

The debates going on now within the Campaign for a Healthy California are crucial, and they’re informed by earlier failures in Vermont and Colorado. There’s a rift about how to move forward, and it has much to do with the relationship a lot of unions have to the Democratic establishment.

The speaker of the California Assembly, by all accounts a pro-labor Democrat, has bottled up a Medicare-for-All bill in an administrative committee and refused to release it. Some want to go after the Democratic establishment. Other unions take a more cautious approach; they want to softly influence the process.

You have to talk about how to move into the endgame; that’s how you find out who your friends are. You have to confront the Democratic establishment. It’s bringing out all the fault lines both within labor and in the broader movement.

Similar things will happen in New York as they get closer to victory. So one thing we’re doing with the Labor Campaign for Single Payer is to prepare labor supporters for the next push.

We’re trying to make sure the internal questions people have are answered, so that for the endgame we are unified. We are working with unions that have Taft-Hartley-style funds [multi-employer funds run jointly by union and employers], for example, and making sure we’re in touch with the bill’s sponsors so that all the good things about those funds are preserved when the bills are final.

We’re hoping to do a similar project with public employee unions, which still have pretty good health care in New York, and there are tensions about what would be gained or lost by supporting single-payer.

So, while there are problems with state campaigns, if we can’t win it in New York, which still has Canadian levels of union density, it’s not clear where the path forward would be.

We don’t think we can win it exclusively state by state; you’re never going to crack Alabama. We think some breakthrough victories in key states will reignite a national movement, and ultimately we have to win it nationally.

You have to find cracks in the edifice and pry them open. If we win single-payer in some states, some sections of the employer class would rather deal with one national system and might be willing to entertain the idea at the national level.

In theory, it would be easiest to implement one national health system with one piece of national legislation — like HR 676. There are some real problems involving the financing and efficiency of implementing single-payer on a state level. But, from an organizing perspective, the path to Medicare for All will probably run through the states.

That it’s the biggest tax increase in the history of the world. That it will decimate people’s pocketbooks. This is because you are moving from a fragmented privatized system to a social insurance system. All of the expenses that are currently being paid from a number of sources will now be paid by a single payer using equitable public financing. Even after we eliminate profit-taking and waste from the system, health care is still extraordinarily expensive.

People need to understand what they’re currently paying for health care and do some kitchen table economics. Yes, I will pay more in taxes, but I will no longer be paying $200 a month out of my paycheck and $50 every time I need a prescription, so this would be a net gain.

When they were trying to pass an initiative in Colorado, folks made an online calculator where you could plug in your own economic information and figure out what you currently pay and what you would pay under their proposed system. It’s education in a deep way.

The medical-industrial complex will also raise rationing of care and government control. They’ll say, “The government can’t even run the Department of Motor Vehicles . . .” I think a lot of those arguments have been discredited. People know their care is already rationed, by ability to pay, and that it’s administered by bureaucrats.

Originally published at Labor Notes.