Five years ago, a single-payer or ‘Medicare for all’ healthcare model in the United States was considered a pipe dream by all but the most progressive voters. Today, half of all Americans, almost two-thirds of Democrats, 15 U.S. Senators, and the majority of Democratic representatives support the plan. Although the idea is young, it has taken a long and arduous political path to popularity—and it may have an even longer path ahead.

The history of successful left-wing healthcare reform in the United States is sparse; only a handful of initiatives have ever passed into law. Between each of these successes were many failed initiatives, all marked by conflict with special interest groups, party infighting, and insufficient Democratic control of Congress. History shows that for the Democratic Party to pass single-payer legislation, they must  gradually build upon existing reform. ‘Medicare for all’ may be a powerful rallying call, but Democrats will have to start with more modest expansion.

Origins of National Healthcare

The Democrats’ first major push for healthcare reform came in the 1940s, when Harry Truman proposed America’s first universal healthcare model. The plan was attacked by opponents who labeled it “socialized medicine,” capitalizing on anti-Communist fervor. Sen. Robert Taft (R – Ohio) called it “the most socialistic measure this Congress has ever had before it,” and the American Medical Association described the Truman administration as “followers of the Moscow party line.” With a record-breaking onslaught of lobbying by the AMA, the bill eventually died in committee.

A decade and a half later, the healthcare debate sprung up again. Members of Congress developed a new proposal—dubbed ‘Medicare’—that would provide free healthcare to all of America’s seniors.  At a time when 30 percent of the American workforce was unionized, organized labor fervently backed the proposal. Once again, the AMA and the insurance lobby fiercely campaigned against the program, repeating familiar labels of “socialized medicine.” AMA President Edward Annis warned that Medicare would “put the government smack into your hospital.” The debate raged on for several years, but the bill struggled to get through Congress, and by 1960, it appeared to be stalling out.

This all changed when Democrats won landslide victories across the country in 1964. “Medicare would not have been passed … if Lyndon Johnson hadn’t had the biggest swing … that had been seen in years, and the House and the Senate dramatically moved [toward] Democrats,” polling expert and Harvard School of Public Health professor Robert Blendon told the HPR. “Everybody thinks Medicare was inevitable—it wasn’t inevitable.”

Even with union support, healthcare reform required complete Democratic control in Congress to stand a chance at passage. Furthermore, consensus among Democratic legislators grew substantially. “Many Democrats who were elected were, in fact, much more liberal than any that had been in the seats previously,” Blendon explained. United, liberals were able to take advantage of their electoral gains to pass reform.

Importantly, liberals in Congress also exercised some degree of restraint. In passing Medicare, they refrained from attempting a complete healthcare overhaul, instead providing healthcare only for Americans over the age of 65. A full single-payer program could have faced lethal opposition from constituents and moderates in Congress. Putting their political strength toward incremental progress ensured successful reform for the Democrats.

45 Years of Failed Attempts at Reform

The time period between the passage of Medicare in 1965 and the Affordable Care Act in 2010 saw periodic pushes for reform, but all fizzled out or resulted in minor amendments to existing programs.

Competing special interest groups often stymie healthcare reform when incremental change cannot be agreed upon. In the 1970s, Capitol Hill came closest to achieving reform when Senator Ted Kennedy worked to pass an essentially single-payer national health insurance program, while President Nixon supported a private-sector-based program. Neither bloc had the votes to pass its proposal alone, so they worked toward a compromise. However, purist special interest groups on both sides thwarted their efforts. The AMA and business lobbies once again decried the compromise as “socialized medicine,” while labor unions insisted the plan was unambitious and too soft on insurance companies.

In 1993, President Clinton proposed another attempt for universal healthcare. From the beginning, the plan was weakened by the Democrats’ lack of a united front on policy issues, and a familiar and expanding pushback by insurance and business lobbies. Furthermore, shrinking unions could not provide the kind of support they offered during the 1960s push for Medicare. Like those before it, the proposal died in Congress.

These examples illustrate how the increasing polarization of healthcare politics poses an enormous barrier to reform. Blendon told the HPR, “the parties have become so polarized that … it depends on which party will be [in power].” Even when Democrats are in power, they need to be completely united to pass reform. And overambitious proposals can exacerbate potential policy divisions within the party. For these reasons, more than four decades passed without successful reform, as Democrats failed to assemble the necessary electoral power and political will.

Obamacare and a New Single-Payer Movement

In 2010, the dry spell of healthcare reform was broken with the passage of the Affordable Care Act. Much like the passage of Medicare, 45 years earlier, the passage of the ACA relied on a perfect storm of Democratic policy consensus and strong Democratic majorities in Congress.  The bill struck a balance between universalizing healthcare and protecting insurers, and even earned the endorsement of the AMA. The proposal narrowly succeeded on purely partisan lines, receiving not a single Republican vote in the House or the Senate. The Democrats—including every Democratic Senator—rallied around the bill. Importantly, liberal Democrats accepted this incremental step toward universal coverage, rather than fixating on dreams of single-payer.

Emboldened by the progress made in the ACA, liberal activists ramped up the drive for a fully single-payer system. Popularity for single-payer shot up over the next several years, and serious proposals were taken on in California, Vermont, and New York. Democrats had total control of the state governments in California and Vermont, but they struggled to unite behind one plan to resolve policy details. Democrats were “basically [having] a civil war among themselves,” explained Paul Song, the co-chair of the Healthy California Campaign for single-payer. The plan in Vermont had several opponents in state Democratic leadership. Meanwhile in New York, Democrats lacked the votes to pass their single-payer bill through the state senate, which has a narrow partisan split.

In each of these state proposals, Democrats either failed to coalesce around one set of policy solutions, or lacked the partisan votes in legislature. They failed to focus on incremental reform measures, meaning that  the proposals on the table would have required tremendous political will to pass. These are the same overwhelming challenges that doomed national Democratic healthcare reform for 45 years, so it is clear that any reform would require another perfect storm of Democratic electoral success, policy consensus, and pragmatic focus.

In Washington, the first steps are now being taken toward single-payer healthcare. However, the barriers it faces are familiar and taller than ever. “The fact that we’re battling just to keep what we have with the Affordable Care Act should really question anybody who thinks we’re going to suddenly go radically leftward,” MIT economist and Obamacare architect Jonathan Gruber told the HPR. Democrats have put together single-payer proposals in the House and the Senate, but they continue to lack both a policy consensus and the partisan votes to pass a bill. Four Democratic senators currently oppose the single-payer ‘Medicare for All’ bill proposed by Bernie Sanders (I – Vt.), whereas no Democratic senators opposed the Affordable Care Act in 2010. Gruber, who also worked on the single-payer proposal in Vermont, is skeptical that political consensus is possible on single-payer. “There’s 800 billion reasons why the insurance industry would spend money attacking it,” Gruber added, referring to the annual financial size of the health insurance industry. Furthermore, with Democrats firmly in the minority in Congress, even a Democratic policy consensus would not be enough to pass reform. Single-payer may be gaining momentum in Washington, but it has a long way to go to circumvent the problems that have held back reform in the past.

History has shown that America will not achieve single-payer in one fell swoop, but Democrats can still chart a pragmatic path forward. Gruber told the HPR, “I could see a light form of the public option coming about,” referring to a potential reform in which the government would promote non-profit competition on the Obamacare exchanges. In November, the HPR reported on cost-cutting regulations proposed by Democrats in the Massachusetts Senate. If Democrats can accomplish more liberal reforms like these, it will move the country closer to an eventual single-payer system. Impassioned rhetoric on ‘Medicare-for-All’ may be a powerful rallying call for the Democratic base, but successful reform can only come through concrete incremental change.

Image Credit: Molly Adams/Flickr

Correction: An earlier version of this article incorrectly stated that Democrats won landslide victories in 1960 rather than 1964.

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