Irene Aguilar knew for a long time that America's healthcare system was broken. She had worked as a doctor in one of Colorado's "safety net" hospitals, where the uninsured and seriously ill go for care. Some of her patients were there because they had lost insurance after being laid off, others lost insurance because they divorced a spouse whose job had been providing it. Who qualified for insurance-covered care could seem cruel and nonsensical. The "classic example," she told me, were diabetics who wound up on dialysis because they couldn't afford the medications that would let them manage their condition.
"Once you're on dialysis, you automatically qualify for Medicare. I was furious that I had patients who had worked all their lives and they end up on dialysis and they can't work anymore and we give them full coverage," she said. "It seems so fiscally irresponsible that we didn't help them control diseases and prevent high-cost complications that would lead to premature death—but once they had those complications we paid for them."
But Aguilar didn't understand the politics of healthcare fully until 2007, when she was invited to participate in a Colorado state commission studying healthcare reform. The mother of a disabled daughter, Aguilar was assigned to a subgroup focused on the problems facing "vulnerable populations." Not used to that kind of committee work, she found the sheer amount of talking overwhelming, almost "painful," she told me. But she's proud of the conclusions her group reached: Since even the insured can lose health insurance due to unemployment, thrusting them into sudden crisis, everyone in America could accurately be described as "vulnerable." The current system wasn't just failing the sick and needy, it was failing, full stop.
The solution was pretty obvious to Aguilar and many of the people working alongside her: A "single-payer" system, also called "Medicare for all," where the government provides health insurance to everyone and pays hospitals and doctors for services directly. Not only would that have made Colorado's population at large less vulnerable to the whims of employers and the insurance market, it would have saved the state an estimated $1.4 billion by cutting down on the overhead and waste inherent in a system where for-profit insurance companies serve as middlemen.
"Being politically naive, I thought, Well, this is what the commissioners are going to pick," Aguilar said of the various proposals on the table. "Then I learned about politics of healthcare and healthcare reform."
She went on: "I literally sat behind one of the commissioners [at a meeting with politicians] to make sure that when they made their report to the legislature that they told them there was a plan that covered everybody and saved $1.6 billion, because I was still naive enough to think that would sway them. And one of the legislators said, 'Yeah, but that's the single-payer plan, right?' She said, 'Yeah.' So they said, 'Tell me about the next one.'"
The commission's final report, released in January 2008, didn't exactly deliver on Aguilar's dreams; it suggested the state require residents to buy insurance and give them subsidies to do so, among other things. That proposal resembled the Affordable Care Act, a.k.a. Obamacare, which became federal law a couple years later and was nearly gutted by Republicans in Congress last month.
Aguilar's disappointment in single-payer not being given a fair hearing is familiar to anyone who's converted to the cause of universal, government-provided healthcare in America. People like Aguilar, who was appointed to the Colorado State Senate in 2010, believe healthcare is a right. They point out that United States fails to provide care to many millions of people, resulting in thousands of deaths annually, while spending way more than comparable nations. Expanding Medicare so that it covers everyone is a far simpler, more politically coherent reform than the complicated carrot-and-stick approach of Obamacare; it would also insure a lot more Americans. Sure, taxes would have to go up to pay for this new system. But some economists say people would pay less overall because private insurers spend money on advertising and other expenses the government could ignore.
As Aguilar found out the hard way, the problem facing single-payer advocates is not fighting Republicans—who will probably never support such a dramatic expansion of government in the first place. Instead, it's convincing Democrats. A combination of the insurance lobby's influence, the power of anti-government rhetoric, and many politicians' natural caution has turned single-payer into a political orphan, an impossible dream. But these days, the left wing of the Democratic Party is rising in anger to challenge both Donald Trump and Clinton-esque moderates, unafraid of adopting positions that were once dismissed as "socialist."
At times, support for single-payer can seem almost messianic. Though the details of a "Medicare for all plan" remain vague, the basic idea that the government could reshape the health insurance system to be fairer, more efficient, and more humane is so powerful that it can grip its acolytes with something like genuine faith. That faith in turn has kept them hoping—and organizing, and writing quixotic bills—even when their cause seemed hopeless. But now they're closer than ever before.
All they need are political leaders who agree with them.
Single-payer initiatives have failed again and again in recent years, even in states under Democratic control. A 2014 effort in Vermont was scrapped after then Governor Peter Shumlin, initially a strong supporter, said it would raise taxes too much. In California, where Democrats dominate the entire government, the speaker of the state assembly removed a popular single-payer bill from consideration this June, insisting it was "incomplete." (It would have added $200 billion in new spending to the state budget.) Last year, a Colorado single-payer ballot measure was defeated easily even as Hillary Clinton won the state in the presidential election.
And those are just some of the more high-profile efforts—most of the time, single-payer bills are introduced in state legislatures or on Capitol Hill only to disappear into committees without a trace.
A national health insurance system has been a holy grail for leftists since the days of FDR and Harry Truman. Former Michigan congressman John Dingell Jr., whose father, also a congressman, supported a government health system, introduced a single-payer bill in 1956 and kept introducing it until 2009, when the Obamacare debate began. But though the cause was embraced by many figures over the years—Martin Luther King said in 1966, "Of all the forms of inequality, injustice in health is the most shocking and inhuman"—it remained relatively marginal. In the 1970s, a push for universal coverage led by Massachusetts senator Ted Kennedy went nowhere.
Health insurance became a more major issue in the 1980s, according to a history from the American Journal of Public Health, as the ranks of the uninsured grew. Relatively new groups like Physicians for a National Health Program began to make noise, and there were calls for government healthcare in places like the New England Journal of Medicine.
Rita Valenti was part of that push. A 68-year-old registered nurse in Georgia's Dekalb County, back then she knew what a disaster the current system was from working at a safety net hospital, like Aguilar. In 1990, Valenti remembered, Georgia healthcare advocates looking at the state legislature "decided, 'Let's go for it! Let's run a candidate who's promoting single-payer and see what we can do.'"
Valenti was that candidate, and she won a Georgia House seat in 1990. "We campaigned on single-payer very openly. We did door-to-door canvassing throughout my district," she told me, with the campaign focusing on "a lot of education about what a single-payer plan should be."
Valenti didn't think that the Georgia legislature would actually pass a single-payer bill, but she introduced one anyway in 1992, the same year Bill Clinton won the White House. The Atlantic Journal-Constitution published some fairly positive coverage of the proposal and ran an op-ed from Valenti. She told me it had strong support in a poll her group commissioned. But it went nowhere, just like the similar bill introduced in Washington State two years earlier—just like the federal bill pushed by Chicago congressman Marty Russo the next year, just like all the bills that followed.
Single-payer supporters often cite polls showing support for the idea of more people having insurance and healthcare (if not a single-payer system in particular), but there's a gap between public enthusiasm and the caution of legislators. Not many politicians, even liberal ones, have been ready to embrace a policy that would raise taxes, kick people off of their employer-provided plans, result in jobs being lost in the insurance industry, and give the federal government authority over a huge part of the economy and an important part of people's lives.
But some politicians have embraced single-payer anyway and have fought for it for a long, long time.
Richard Gottfried was first elected to the New York State Assembly from Manhattan when he was a 23-year-old law student in 1970. He's been there ever since. In 1987, he became chairman of the Assembly Health Committee, and a few years later met with a group of single-payer advocates. "To me it was like a lightbulb going on moment, and I have been firm believer ever since then," he recalled of his conversion.
In 1992, Gottfried introduced his first bill proposing a state single-payer system. It didn't get passed, so he introduced another bill the next year and has kept on doing that every year since, even as the flurry of single-payer coverage subsided after the early 90s. The healthcare debate soon revolved around a proposed plan from Bill and Hillary Clinton that mandated people buy private insurance, much like the Affordable Care Act did.
"That became the only game in town," Gottfried said. "While there were many single-payer advocates who stuck with exclusive support for single payer, the Clinton plan took a lot of wind out of those sails. And the same thing happened with the Affordable Care Act."
Now single-player is once again looming large in the liberal imagination, with a majority of Democrats—and a third of the country—favoring the idea (just three years ago, only a third of Democrats and 21 percent of Americans supported it). That rise is probably thanks in large part to longtime advocate Vermont senator Bernie Sanders, who made it a centerpiece of his surprisingly strong challenge to Hillary Clinton in last year's presidential race. And single-payer support has become a litmus test for progressivism in the Trump era; Massachusetts senator Elizabeth Warren endorsed it this summer, while other prominent Democrats have been a little bit more cautious—the furthest Senate Minority Leader Chuck Schumer would go is to say that single-payer is "on the table."
"He's coming around, but [Schumer] is one of these triangulating Democrats, finding the middle of where Democratic politicians are," said Benjamin Day, executive director of Healthcare-Now!, a single-payer advocacy group. "What a lot of Democrats want to do is say they support healthcare as a right, and it shouldn't be a commodity, but they refuse to endorse any policy that would protect that right."
Democrats face several obstacles on the road to single-payer. Most obviously, there's the insurance industry, which would be wiped out—or converted to the nonprofit sector—in a single-payer system, and donates heavily to politicians. (The industry has also opposed reform, notably in the 90s.) Some single-payer advocates say insurance money co-opted California legislators.
"Too many Democratic officials, whether at the state or national level, raise a significant amount of money from health insurance companies, from big pharma, in some cases from hospital executives," Massachusetts state senator Jamie Eldridge told me. "There's a feeling that if we embrace single-payer a lot of that money will go away, and then somehow Democrats won't be able to win elections."
Eldridge is the sponsor of another probably hopeless single-payer bill and recently helped get a plank on the issue in the platform of the state Democratic Party. He thinks that even though single-payer scares the powerful insurance lobby, it's the kind of stand that would show that the Democrats have something different to offer than Republicans.
"Part of the problem with the Democratic Party is it's too corporate-influenced and doesn't have a bold message on a variety of subjects," he told me. Trump can talk about "insurance for everybody," after all. Why can't Democrats do the same and mean it?
It's not simply donations from insurers holding up progress. "You can't have a healthcare system that saves money and does not cause job loss in the industry," Day said. And no politician wants to be responsible for the loss of jobs. Day admitted that's an issue even though he believes, like other advocates do, that a single-payer system would lift up other parts of the economy as employers no longer have to pay for their workers' insurance.
And if single-payer supporters can sound persuasive when they talk of inequality and a universal right to healthcare, the talking points of their opponents have been more effective. Conservatives often denounce the healthcare systems of other countries, where a greater percentage of the population often has access to care and less is spent on it. But, they say, Canada's single-payer system has long lines, while (according to right-wing site the Blaze) "socialized medicine" resulted in a baby being sentenced to death in the UK.
"It's so much easier to convince people to say no than to convince people to say yes," Aguilar, the Colorado state senator, told me. She thinks Coloradocare lost at the ballot box so badly last fall partly because it was linked to bigger government. Locally, people remember a VA hospital construction project that became a financial disaster—if government can't handle one hospital, how can it handle a single-payer system?
"We never came up with a good soundbite that resonated with people," Aguilar said of Coloradocare. How do you get people to agree to a tax increase? She's still not exactly sure what she would have changed about the message but thinks that more of a focus on "cutting waste"—getting the hated insurance middleman out of healthcare—could be a start.
In New York, Gottfried's latest single-payer bill has gotten more attention and success than his previous efforts, with every Democrat in the state senate supporting it. That's still not enough to get it to Governor Andrew Cuomo's desk however, and it's not clear if he'll sign any such bill. Gottfried told me opponents were calling the bill "Obamacare on steroids" and "Albanycare," a particularly nasty moniker given the state capital's reputation for corruption and bad governance.
There are more local obstacles to single-payer, too. Colorado's constitution has barred public money from funding abortions since 1984, meaning the proposed Coloradocare system might have restricted access to abortion. As a result, pro-choice progressives opposed the measure, making an already heavy lift impossible. In California, even if a single-payer bill passed it would probably get challenged at the ballot box by the insurance industry, according to Day.
Compounding all this is Democrats' urgent need to get themselves back into power both in DC and in statehouses across America, where they've lost significant ground since 2008. "Right now there's a lot of Republican control and a lot of fear," Aguilar told me. Democrats fighting to claw their way back to power while running against an unpopular president don't want to take on the additional risk of endorsing a controversial new big government program.
Republicans, meanwhile, are so confident single-payer is a political loser that during the recent healthcare debate, they tried to force Senate Democrats to vote on it. (The vast majority abstained.)
The most passionate single-payer advocates think that Democrats need more voices like Sanders, who unambiguously make big promises and don't waffle.
"By embracing a bolder, clearer message and putting healthcare as a right, we'd be more competitive in a lot of races," Eldridge, the Massachusetts state senator, told me. Like others, he thinks that unions, a traditional Democratic power base, need to get more aggressively behind the policy.
At the federal level, a House single-payer bill, the latest in a long line, is preparing to die a noble death. Sanders has promised to introduce a complimentary bill in the Senate, which his allies hope will attract widespread support among Democrats (it has no chance of passing). If Democrats take back Congress, some progressives hope that they'll ram single-payer through, taking a page from the Republicans' anti-compromise playbook rather than trying to build consensus as they did in the Obama years. (Given the decades of Democratic hesitation on the issue, that seems unlikely.)
California's bill is not yet dead, however, and angry activists are hoping to kick its chief Democratic opponent out of office. Maryland liberals are hoping to elect a pro-single-payer governor next year. Many advocates hope that if they can get just one state to launch a successful single-payer system, others will follow until a federal system is an inevitability (this is more or less how Canada got its system, which started in the Saskatchewan province).
Gottfried has watched as enthusiasm has waned and waxed over the last quarter-century. The rise of new pro-single-payer groups in New York, and the increased media attention, is obviously good news to a longtime devotee like him. But he doesn't sound worried that his latest single-payer bill will fail. If it does, it won't be the first time—it'll be the 26th. Single-payer supporters are by nature optimistic (at least when talking to reporters) but also very, very patient.
"This is not a fight for people with a short attention span, to say the least," Gottfried said. "But I am convinced that popular opinion and the forces of economics will prevail."
Follow Harry Cheadle on Twitter.