What Good Is a Nod and a Wink?

It is true that the platform states that, “We are proud that our party welcomes advocates who want to build on and strengthen the Affordable Care Act and those who support a Medicare for All approach.” Some progressives view this as a victory. The HuffPost proclaimed that, “Medicare for All Gets Nod In Democratic Platform for First Time Ever.” And Politico quoted the Sanders campaign political director, Analilia Mejia, as saying, “Support for Medicare for All has never been mentioned in a Democratic Party platform. Its inclusion now is significant.”

(While technically true — because they did not call it Medicare for All back in the day — it should be pointed out that robust support for “national health insurance” embodying the same principles as current Medicare for All legislative proposals was a regular part of Democratic Party platforms from the New Deal through 1980.)

This concession is weak tea indeed considering the depth of the crisis we are now in and the concomitant paradigm shift in Americans’ thinking about health care. Our for-profit, commodified health care system has proven woefully inadequate in the face of the worst public health disaster in over a century.

The resulting economic crisis has accelerated the meltdown of our employment-based health insurance system. Workers will not soon forget how precarious their shrinking health care benefits really are. And the Black Lives Matter uprisings have brought to the fore the racial disparities that undergird the industrialized world’s most unequal health care system. Democratic primary voters overwhelmingly supported Medicare for All regardless of what candidate they voted for.

A more recent poll conducted at the peak of the COVID-19 pandemic pegged overall support at 68 percent with even 46 percent of Republicans supporting. So please excuse me for refusing to celebrate the nod and wink to the Medicare for All foot soldiers who will now be expected to do what it takes to elect a Democratic nominee who, at one point in the primary cycle, suggested he would veto Medicare for All legislation.

Don’t get me wrong. I fully understand the existential threat posed by the incompetent, authoritarian, racist madman in the White House. Come Labor Day I will do my part to work for his defeat. But first let’s take a moment to lament what could have been and figure out what needs to be done to advance the fight for health care justice in 2021 and beyond.

The Good, the Bad, and the Ugly

The draft Democratic Platform’s health care provisions contain a number of substantial policy proposals worthy of support. It calls for a massive expansion of community health centers and rural clinics, greater access to mental health and substance abuse treatment, improvements in long term care, and it proposes a workaround to cover the working poor ineligible for Medicaid because of their state’s refusal to accept federal funding for ACA Medicaid expansion. It would fully fund the Indian Health Service and it asserts all health care workers’ right to a living wage and to bargain collectively free from employer coercion.

Consistent with the Democratic Party’s historic stance on these issues, the platform reaffirms support for the full range of reproductive health services, including access to abortion. It also proclaims the Party’s commitment to address the health care needs of the LGBT communities. It stakes out a strong position on ending price gouging by Big Pharma by calling for drug price negotiation authority for all public and private purchases, and a crackdown on anti-competitive behavior “by any means available.”

It also includes some puzzling provisions that seem to indicate either a lack of understanding of health care policy or a deliberate attempt to undermine the very proposals it claims to be advocating. For example, it repeats Joe Biden’s campaign plank to lower the eligibility age for Medicare down to age sixty, but then treats Medicare as if it were just another insurance product by making it one “choice” that older Americans would be allowed to make.

And it appears to view racial disparities as a problem caused by its victims’ lack of adequate knowledge rather than the result of systemic inequalities baked into the health care system (“To help close the persistent racial gap in insurance rates, Democrats will expand funding for Affordable Care Act outreach and enrollment programs so every American knows their options for securing quality, affordable coverage.”)

One modest concession to single-payer aspirations is the platform’s support for enhanced innovation waivers to remove “barriers to states that seek to experiment with statewide universal healthcare approaches.” A generous reading of this section might indicate that a Biden administration would support a single-payer-style reform such as the pending proposals in New York, California, and other states. But even here the language is vague and fails to mention the actually existing legislative proposal to do just that: Ro Khanna’s State-Based Universal Health Care Act.

What’s Wrong With a Public Option?

The centerpiece of the platform — which it claims will finally move us to the promised land of universal coverage — is the pledge to “give all Americans the choice to select a high-quality, affordable public option through the Affordable Care Act marketplace.”

Like a bad penny, various iterations of this scheme always show up in corporate Democrats’ playbooks whenever a real Medicare for All solution is gaining momentum. The platform proposes a fairly “robust” version that would be available to nearly everyone and cap premium costs at 8.5 percent of household income (although co-pays, deductibles, and other out-of-pocket coasts could add substantial additional expenses).

The public option has been extensively critiqued (including here, here, and here). Suffice it to say that adding an additional public choice in a health care “marketplace” perpetuates the commodification of health care. There are intrinsic problems when public goods, like health care, are treated like commodities.

A system designed to accommodate profit seeking and multiple payers can never achieve the efficiencies and cost savings of a social insurance model. Competing health plans with different costs, co-pays, and deductibles reinforce inequality and disparity, and make a single standard of care unachievable.

Commodified health insurance products also generate all kinds of unanticipated consequences including the dreaded “adverse selection” in which decent coverage is undermined by shoddy insurance plans and for-profit insurers game the system by cherry-picking the most healthy subscribers and finding ways to dump the sick ones on the hapless public plan.

Adding an additional choice will do nothing to bend the cost curve of the world’s most expensive health care system. Nearly all economists concur that Medicare for All would achieve 20 percent to 30 percent savings because of lower administrative costs and limitations on profit taking. Without those cost savings, we would have to pay “market rates” to expand affordable coverage to the 40+ million uninsured Americans and the 50+ million underinsured ones. No one has even begun to calculate how much those additional costs would be.

Most importantly, the Democratic platform does nothing to break the continued linkage of health insurance to employment. This failing system deprives working-class Americans of the health care security that they want and deserve, and is a major driver of wage stagnation. To seek to sustain such a system at a time when one million workers a week are losing their jobs — and hence any possibility to access employer-paid health coverage — is an indefensible failure of vision.

The stress test of the COVID-19 pandemic has exposed all of the flaws of our dysfunctional health care system. It failed us at the time when we needed it the most. Reality calls for transformative change. The Democratic platform offers up a few patches.

Fight for What We Want, Not What We Think We Can Get

I’m willing to bet that nearly all of the 125 DNC Platform Committee members who voted against the Medicare for All amendment would agree that a single-payer Medicare for All system would cost less, cover more, and deliver better health care. But they would maintain that Medicare for All is not politically feasible. Their mantra is, “Don’t let the perfect be the enemy of the good.”

In effect, they are saying that the power of the medical industrial complex is so great that it can forever stifle the clearly articulated political will of the majority of the American people who support a demonstrably superior health care system.

The problem with this, as any shop steward who ever sat across the table from a boss knows, is that when you start negotiating by conceding your opponent’s points, you have nowhere to go but downhill. Frederick Douglass had it right: “Power concedes nothing without a demand. It never did and it never will. Find out just what any people will quietly submit to and you will find out the exact measure of injustice and wrong which will be imposed upon them.”

Proponents of this approach believe that clever policy proposals will somehow get us to health care for all without the necessity of an all-out fight. They are like Douglass’s sunshine soldiers who “want the ocean without the awful roar of its many waters.” But, as the history of the Affordable Care Act shows, once single-payer is taken off the table, the medical industrial complex will move to gut the public option and any restrictions on insurance and Big Pharma profits.

The Pathway to Victory

Michael Lighty, the mover of the Medicare for All amendment at both the 2016 and 2020 DNC platform hearings, said at this year’s hearing, “It’s vital that we meet this moment that demands health justice and Medicare for All to address the health inequities exposed by the COVID 19 pandemic…Nobel Prize winning economist Angus Deaton has said has said that private insurance financing is an engine of inequality in our system…We cannot solve it with a public option.”

Medicare for All has won the battle of ideas. Now we have to win the battle against entrenched economic and political power. This fight won’t be made any easier by harboring illusions that we can somehow compromise our way to victory. Every country in the world that recognizes health care as a right for all of its citizens did so in response to a powerful working-class movement backed by unions and grassroots organizations.

In the United States, the passage of Medicare and Medicaid in 1965 was driven by an alliance between the labor movement and the civil rights movement. It was seen as the first down payment on the social and economic justice principles embodied in the Freedom Budget proposed by A. Philip Randolph and Bayard Rustin. Our task today is to construct a similar movement that sees Medicare for All as the tip of the wedge in a broader fight for social and economic justice.

Such a movement will come together not in alliance with a deeply compromised Democratic establishment but in opposition to it. Labor must be central to this movement and part of our challenge is to work to extract union officials from their instrumental relationships with the Democratic Party. Likewise the movements for racial justice must contend with a black political and managerial class that has made its own peace with neoliberalism.

Arguably these tasks will be somewhat easier when the country is not facing the stark political choice between barbarism and civilization.  Furthermore the unfolding economic and public health crises will continue to thwart any return to normalcy.

A newly installed Biden administration will face intense pressure to embrace an austerity program that will create immediate fissures in his electoral coalition and new opportunities for working class politics. These tensions cannot be papered over. This is why I am convinced that Medicare for All will continue to drive the political agenda no matter what the Democratic platform or the Biden campaign has to say about it.

Let’s Take Them at Their Word

So the Democratic Party “welcomes advocates of a Medicare for All approach”? Well then, why don’t we take them at their word?

We will do our part in working to drive this murderous regime from the White House. We will work to turn this election into a referendum on the right of all Americans to health care. We will promote congressional and state-level candidates who have pledged to support real health care reform. We will continue to support robust social insurance fixes to the ongoing pandemic and economic crises such as the Health Care Emergency Guarantee Act.

On Election Day we will celebrate the defeat of Trump and work to excise Trumpism’s corrupting influences on our political institutions and civil society. And on Inauguration Day we will raise the flag of Medicare for All as the rallying cry for a new movement for social and economic justice.