The Way To Save the ACA is to Fight For the ACA

There was a controversy this weekend that ended up in the Twitter mentions of at least one LGM front pager in which Tom Perez was criticized for calling for unity after Jon Burton made a dumb comment telling protestors to shut up and go outside. I understand the criticism of Burton, but when it comes to Perez I don’t understand what I’m supposed to be upset about. He didn’t express any kind of opposition to single payer; he just made the rather banal point that the immediate focus should be on stopping Trump/Ryan/McConnell’s savage cuts to American health care.

Admittedly, I don’t most of the criticism of Perez is part of a considered strategy to either stop the AHCA or attain single payer; the sole point of the criticism is “Tom Perez is a shill imposing neoliberalism on the Democrat Party.” But the tactical questions are of considerable immediate interest. My friend Sam Bagnestos, a professor at the University of Michigan law school, agreed to let me publish an email he sent on this subject, which I fully endorse:

I’m for single payer (though I am open to any means that will get us to the goal of truly universal and really good health care coverage). And wonks on the left should be developing single payer proposals and building constituencies for them, so that we are prepared when there is an opening to get them passed.

But right now the president is proposing to cut Medicaid by $800 billion. That’s going to devastate millions of poor, working, and disabled people (overlapping categories). In every disability advocacy project I’m working in right now, this is the most important fact — the issue we all have to talk about, because if Trump gets his way we can forget about achieving whatever it is we want to achieve in the project.

So for me in the healthcare world, job one right now is fighting the Medicaid cuts, to protect the millions of poor, working, and disabled people who will have their lives devastated if the cuts go through. And I would hope that everyone who is pro single payer will join me in that defense right now. That might mean joining with a lot of people who don’t like single payer — at least not now — but can be persuaded to fight Medicaid cuts, and who, with some time fighting alongside single-payer advocates, might become allies in future offensive efforts.

I keep hearing, from a lot of people I like and respect, that we can’t do defense without agreeing on ambitious offensive goals. I don’t think that assertion is true as a practical matter. It’s often a lot easier to pull together a defensive coalition, among people who might disagree on what offensive goals to pursue next, then to pull together a coalition to pass new, expansive legislation. The Madisonian system is a big reason. So is basic psychology like the endowment effect and loss aversion.

I think the no-defense-without-offensive-goals line, in the healthcare context, really means one of two things: (1) Any political effort spent defending a non-universal system is counterproductive, because it cements in the public’s mind the association of government healthcare with welfare and other programs that many people will see as taking from “us” to give to “them.”  (2) Trump is probably going to get his way anyway, and when he does, the results will be so disastrous that we will finally have a real political opening for single payer.

As to (1), that’s really an empirical question.  But I think a lot of people who have an ideological preference for universalism in social programs treat the answer as obvious without engaging in any empirical analysis.  I, for one, would want to be damn sure that defending Medicaid was counterproductive before deciding to sacrifice the millions of poor, working, and disabled people who would lose out with Trump’s cuts.  And my own experience is that the example and testimony of people with disabilities and their families in relying on Medicaid opens up a nice solidaristic defense of the program that can lay the groundwork for future efforts to promote universalism.

As to (2), maybe.  And certainly that’s a reason for wonks on the left to be constructing and building support for single-payer proposals (and for political operators to strategize regarding how to exploit the opportunities that open up).  But none of that precludes fighting right now against Trump’s Medicaid cuts — and fighting alongside some folks who may not agree on single payer as a goal.  Trump may not get his way — there is a path, though hardly a certain one, to defeat those cuts.  And if he does get his way, even if the result is to open up more political space for single payer, that doesn’t make single payer certain or even likely to happen — and it certainly won’t happen before 2021.  Even after 2021, the problems Charles Gaba talked about are basically going to remain.  If the Medicaid cuts happen, and they create a political opening, let’s make the most of it.  But given the uncertainties regarding the political opening, and the certain devastation to lots of poor, working, and disabled people if the cuts go through, I see no reason not to fight like hell against those cuts.  And I certainly see no reason for single-payer advocates, who should be trying to expand the coalition, to be attacking people who think defense is job one right now.

I will admit to some frustration that, among many people I like and respect, the foregoing hundreds of words will confirm the conclusion that I am a neoliberal corporate shill.  But, honestly, I’ll even take the label if everyone can agree that we need to fight like hell against stuff like these Medicaid cuts.

This is exactly right. The way to save Medicaid from immediate attack is to…fight to save it and fight against the extremely unpopular AHCA, not to focus on attacking the ACA from the left. This is in no way inconsistent with preserving the ultimate goal of truly universal health care — the two most likely 2020 nominees right now, Sanders and Gillibrand, both have been longtime supporters and even if someone else is the nominee it’s nearly certain the Democratic nominee will support it too. There will be plenty of time to focus on advocating an affirmative plan for universal health care. But right now, the fight has to be to do whatever can be done to keep Republicans from destroying the ACA, which would both create a great deal of death and suffering and make attaining universal health care more difficult. And, by definition, the legislative coalition to stop the AHCA will require the votes of multiple people who don’t support single payer.