Reviews | Activists should continue to fight for a single national payer rather than taking inspiration from the Democratic Party


It is a mistake on the part of activists to once again allow Democratic politicians corrupted by big money to determine the nature of the fight for single-payer health care. We have to fight hard at the national level to win this. Otherwise, we are abandoning a fight that enjoys strong public support and giving Congress a free pass to do nothing.

The Democratic Party is famous for having diluted and derailed progressive struggles for at least fifty years. And activists have too often been complicit in their own failure by giving in to Democrats.

The United States is not Canada. Due, in large part, to America’s racist culture, successful struggles for progressive state-level policies do not automatically translate into national victories. In his article in Jacobin, Gerald Friedman’s leading example, Medicaid, proves it. The Medicaid program, unlike Medicare, was set up so that states have great discretion and authority over how to implement their own programs. The more “progressive” states of the Northeast and West Coast have had more coverage, fewer restrictions, and fewer means testing in their Medicaid programs for decades. States with more reactionary and racist governments, especially in the South, had more means testing and restrictions leading to less coverage. The better health outcomes of the most progressive states have not led the most reactionary states to see their ways wrong. If anything, these reactionary states have deepened their wounds. In fact, as of this year, 12 states still refuse to expand Medicaid despite the Biden administration’s offer of big “carrots”. Also, my state of Pennsylvania, which currently has a reactionary legislative majority, is taking the example of those reactionary states, and moving in a more regressive direction! Given the racial demographics of states, it may well be that the fact that some states successfully obtain a single payer would mean an increase in racial disparities nationwide.

Southern states did not get rid of slavery or segregation because of the example of the northern states. History shows that, if anything, they took refuge and fought fiercely for their “particular” institutions. It was only when these struggles became national struggles (civil war, civil rights and the struggle for the liberation of blacks) that they were successful.

In addition, it was the implementation of Medicare as a national program that allowed it to have a powerful effect in ending segregation in medicine across the country. Yes, there have been local struggles, but they were expected to fulfill national mandates. It is a mistake to confuse local struggles for national objectives with local struggles limited to local or state achievements.

Proponents of reducing the importance of the national struggle for the single payer (or even putting it in place) to focus on delivering state single-payer programs seem to think that working for state programs to single payer will be a much easier battle. But the peculiarities of the American system of governance and the politics of the HHS, in particular, are likely to make matters more complicated and difficult. Health and Human Services Secretary Becerra, with his turnarounds to be in line with the Biden administration’s health policy, has already shown that he cannot be relied upon to give favorable interpretations of the Article 1332 of the ACA, which allows states to implement their own single-payer programs. And even if Secretary Becerra decides to allow a flexible interpretation of 1332, what will prevent states from being regressive (like Pennsylvania) instead of being progressive?

Finally, there are two suggestions in Friedman’s article that seem confusing. In their article, Friedman et al discuss states using Medicare Part C to establish a single-payer system. But isn’t this essentially establishing a benefit of state health insurance? Is this what we want: privatization of the single payer system up front? Also, they talk about not banning employers from offering separate health insurance. Unless I’m missing something, I can see a multi-state company offering their employees United Healthcare, or CVS offering their employers Aetna, or even better, Walgreen offering their employees a DCE. My experience working as an employee in a large hospital chain is that it wouldn’t hurt them to do this. So, would this state really have a single-payer system?

The Democratic Party is famous for having diluted and derailed progressive struggles for at least fifty years. And activists have too often been complicit in their own failure by giving in to Democrats. Just because Biden establishes Medicare for All doesn’t mean we should or should. We have to do as the Freedom Riders did during the civil rights movement, they forced the hands of the reluctant Kennedy brothers. We need to come together and force reluctant Democrats in Congress to embrace what 80% of Democratic voters and 60% of all voters already support: the expansion of national, single-payer, and health insurance. improved for all, not just some. As Frederick Douglas said: “If there is no struggle, there is no progress. Power does not grant anything without a demand. Let us not be so ready to give in to President Biden’s stubbornness. Continue the fight for the national single payer until we win.


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