Interviews for Resistance: Why the Fight for Single-Payer Is More Important Than Ever

A physician talks about the House vote on Trumpcare and what should happen next.

Sarah Jaffe May 9, 2017

Adam Gaffney is a physician and an instructor at Harvard Medical School. (Physicians for a National Health Program)

Wel­come to Inter­views for Resis­tance. Since elec­tion night 2016, the streets of the Unit­ed States have rung with resis­tance. Peo­ple all over the coun­try have wok­en up with the con­vic­tion that they must do some­thing to fight inequal­i­ty in all its forms. But many are won­der­ing what it is they can do. In this series, we’ll be talk­ing with expe­ri­enced orga­niz­ers, trou­ble­mak­ers and thinkers who have been doing the hard work of fight­ing for a long time. They’ll be shar­ing their insights on what works, what does­n’t, what’s changed and what is still the same. 

"Lives are on the line. Suffering will increase. We have to stop it."

Adam Gaffney: I am Adam Gaffney. I am a physi­cian, pul­monary and crit­i­cal care. I am an instruc­tor at Har­vard Med­ical School and I am active in the orga­ni­za­tion Physi­cians for a Nation­al Health Pro­gram.

Sarah Jaffe: Adam, what the hell are the Repub­li­cans try­ing to do to us?

Adam: Well, if you look at this plan, I don’t real­ly con­sid­er it much of a health­care plan as much as a con­duit of dol­lars from work­ing class peo­ple to rich peo­ple. Because, if you look at it, Sarah, it keeps a lot of the Afford­able Care Act in place, but it den­i­grates it, it twists it, and it cor­rupts it to the ben­e­fit of the very wealthy.

Just from the big pic­ture per­spec­tive, what are some of the things it is doing? Well, on the one hand, it is cut­ting pro­grams. There is a major cut in Med­ic­aid. Over 10 years, we are talk­ing about greater than $800 bil­lion dol­lars in Med­ic­aid cuts. That is about a quar­ter of fed­er­al spend­ing. That is going to throw mil­lions of peo­ple off of Med­ic­aid. As you know, Med­ic­aid is a pro­gram for low­er income peo­ple that cov­ers a lot of Amer­i­cans. More than 70 mil­lion. That is one thing.

The sec­ond thing is it is going to weak­en the sub­si­dies that peo­ple use to buy health plans on the mar­ket­places, the so-called Oba­macare” plans. Those are still going to be around — the pri­vate insur­ance indus­try will still be sub­si­dized — but those sub­si­dies are going to be worse, they are going to be more regres­sive, and they are going to be less ade­quate for many folks. That is one side of the ledger.

On the oth­er side of the ledger there’s just a huge redis­tri­b­u­tion of wealth upwards. Essen­tial­ly, it gets rid of a vari­ety of tax­es that the Afford­able Care Act put in place, and that is almost entire­ly going to ben­e­fit the very wealthy. I am going to read you a cou­ple of num­bers from the Con­gres­sion­al Bud­get Office’s lat­est esti­mates. We are talk­ing about $127 bil­lion dol­lars that peo­ple mak­ing over $200,000 for low­er Medicare tax cuts. $145 bil­lion over 10 years to the health insur­ance indus­try. $172 bil­lion over 10 years for low­ered cap­i­tal gains for high income earn­ers. That is just a few. Big pic­ture, we are weak­en­ing the health­care safe­ty net. We are tak­ing those dol­lars, and we are fun­nel­ing them upward.

Sarah: Because, of course, cut­ting cap­i­tal gains tax­es is very relat­ed to health insur­ance. Right?

Adam: They would argue that this is part of the Afford­able Care Act and that they are sim­ply repeal­ing it, but func­tion­al­ly speak­ing, this is an upward redis­tri­b­u­tion of wealth.

Sarah: This is the sec­ond time, the Repub­li­cans final­ly man­aged to but­ter and squirt this thing through with one vote to spare. What hap­pens next here?

Adam: Well, it goes to the Sen­ate, of course. It faces seri­ous head­winds in the Sen­ate. Many peo­ple are say­ing this. A lot of sen­a­tors are very wary about it effects, par­tic­u­lar­ly on Med­ic­aid. There is much less room for error in the Sen­ate. They can’t lose more than a cou­ple of Sen­a­tors and still pass it through. My gut feel­ing — and I am not very good at polit­i­cal prog­nos­ti­ca­tion, so this is worth what you are pay­ing for it — is that they are going to pass some­thing, but it is going to be a much more watered-down ver­sion of the House bill. Then, the ques­tions will be, Is the House will­ing to pass that?” I don’t know.

Don’t for­get that the Ver­sion 1.0 of Trump­care was sunk main­ly because the resis­tance from the hard right with­in the House, the House Free­dom Cau­cus. They did not feel like the wall went far enough. And that was a pret­ty ugly law. The ques­tions is, How much can the Sen­ate change this bill and still have it be pass­able in the House?” and that remains to be seen.

Sarah: Yes, and there is a def­i­nite sense right now that a lot of the so-called mod­er­ates” who wound up vot­ing for this, did so with the expec­ta­tion that the Sen­ate would change it any­way.

Adam: That is cer­tain­ly the case. I think the expec­ta­tion and the hope that they would change it. I think that there is a real­iza­tion on the part of many mod­er­ates in the House — so-called mod­er­ates” — that this is an ugly, unpop­u­lar bill. The last poll I saw was the one that was being cit­ed around the time of Ver­sion 1.0, if you recall, that showed 17 per­cent sup­port for Trump­care. That is a dis­mal lev­el of support.

Part of that is because, let’s remem­ber what Trump actu­al­ly cam­paigned on. His health­care promis­es were vague, but they aren’t what he is doing now. He said he wasn’t going to cut Med­ic­aid. He said he wasn’t going to cut Medicare. He basi­cal­ly promised more health­care for every­body. So, every time peo­ple sort of chuck­le and say, Oh, I can’t wait to see the Trump vot­ers get what they vot­ed for” on the one hand, I think that is real­ly nasty and is not how we should be approach­ing pol­i­tics. On the oth­er hand — and you can fault them for being poor­ly informed — but, Trump did promise some­thing dif­fer­ent. He promised more health­care, not less. This is just less health­care. It is real­ly a quan­ti­ta­tive switch on health­care spend­ing. It is less mon­ey going into the health­care safe­ty net and more mon­ey going into the pock­ets of high income peo­ple and health­care companies.

Sarah: I thought it would be inter­est­ing because we are talk­ing about, again, this mess of a process of this thing try­ing to get through both hous­es and to the pres­i­dent. Talk a lit­tle bit about the process by which the Afford­able Care Act itself came to be. That was after a sum­mer of yelling at town hall meet­ings from the Tea Par­ty try­ing to stop Oba­macare. So, the thing that end­ed up get­ting through … I won­der if you could talk a lit­tle bit about that process and where the weak spots in that process were.

Adam: I think if you want to look at the weak spots in that process, you have to go back to the begin­ning, which was a rejec­tion from Day 1 of sin­gle-pay­er, of some­thing more expan­sive. In the 2008 pri­maries, the Demo­c­ra­t­ic pri­maries, there was already an assump­tion that sin­gle-pay­er was not going to be an option and basi­cal­ly all of the can­di­dates were opposed to it. That they and Max Bau­cus cer­tain­ly con­ceived of a very much mid­dle-of-the-road com­pro­mise bill from Day 1. I think the biggest flaw in the Oba­macare process was actu­al­ly before the sum­mer of dis­con­tent and before the Tea Par­ty were involved and real­ly start­ing from the assump­tion that we had to do some­thing much more narrow.

Peo­ple talk about this sort of ori­gins of the Afford­able Care Act. Some peo­ple say it is a Her­itage [Foun­da­tion] plan, which is true only inso­far as it incor­po­rat­ed the indi­vid­ual man­date, but it is true that the Afford­able Care Act was large­ly mod­elled on an even old­er plan. It was sort of mod­elled on Nixon’s plan for the 1970s. Ted Kennedy in 1970 put some­thing out there called the Health Secu­ri­ty Act, which is basi­cal­ly a sin­gle-pay­er plan. Nixon put up a counter-pro­pos­al that includ­ed employ­er man­dates, includ­ed expan­sion of a Med­ic­aid-like pro­gram. So, in many ways, even the fatal flaw of Oba­macare was its assump­tion from the begin­ning that we had to involve the pri­vate insur­ance indus­try as a key ele­ment with­in our health­care system.

Sarah: I think it is also worth talk­ing a lit­tle bit about the way that the pol­i­tics around so-called Oba­macare” have played out. You find that peo­ple either don’t know that what they have is the Afford­able Care Act or peo­ple were frus­trat­ed because of the jump from being eli­gi­ble for the Med­ic­aid expan­sion to then sud­den­ly hav­ing to pay out of pock­et even for sub­si­dized care. I won­der if you could talk about the way that the con­struc­tion of this bill made it eas­i­er to attack.

Adam: Well, the con­struc­tion of the bill was that it rein­forced an exist­ing frag­ment­ed sys­tem. It did not cre­ate a new pub­lic ben­e­fit. So, as soon as you do that, you are sac­ri­fic­ing pop­u­lar sup­port. If you look at a pro­gram like Medicare which is a uni­ver­sal ben­e­fit that you get when you turn 65, obvi­ous­ly, it is extra­or­di­nar­i­ly pop­u­lar. Peo­ple know what they are getting.

Under Oba­macare, it is very unclear. Most peo­ple are unsure of how they are affect­ed by the law. It doesn’t cre­ate social sol­i­dar­i­ty in the same way that the uni­ver­sal pub­lic pro­gram does. So, yes, I think that part of the prob­lem with Oba­macare is that every­thing … It frag­ments soci­ety. Now, I think the Med­ic­aid expan­sion was good and it helped a large num­ber of peo­ple, but as you say, many peo­ple in the mid­dle ground are still being squeezed. Deductibles have been ris­ing dra­mat­i­cal­ly in recent years. It is not the fault of Oba­macare. It pre­ced­ed Oba­macare. But, Oba­macare has been blamed for it. Co-pay­ments, deductibles, co-insur­ance are ris­ing. Peo­ple are find­ing that although they are insured, they are unable to afford going to the physi­cian or get­ting a pre­scrip­tion filled. That is a major prob­lem. I think that is feed­ing into a lot of dis­con­tent around this law. I think Oba­macare has not cre­at­ed the social sup­port nec­es­sary for its own prop­a­ga­tion as a result of those inher­ent weaknesses.

Sarah: That said, one of the inter­est­ing things that it did do was, at least, rein­force the idea that the gov­ern­ment should do some­thing about your health­care prob­lems. Then, we do see peo­ple, again, react­ing to the Repub­li­can plan to take away what health­care peo­ple do have with this intense anger.

Adam: Yes. It is amaz­ing — and a lot of peo­ple have said this. There has been a whole shift in the way we think about health­care towards, at least, an implic­it recog­ni­tion of health­care as a right. Charles Krautham­mer sort of said this on Fox the oth­er day, he’s a con­ser­v­a­tive colum­nist obvi­ous­ly. As he said, and I agree, even con­ser­v­a­tives are hav­ing to defend their health­care plan with this implic­it argu­ment that every­body deserves cov­er­age. In a way, that sug­gests that the bat­tle, in the dis­cur­sive realm, is actu­al­ly already being won. Peo­ple increas­ing­ly believe that health­care should be a right.

The fact that the Nation­al Bud­get Office released its esti­mates of Trump­care and said that 24 mil­lion peo­ple would be unin­sured, that was shock­ing. That was ter­ri­ble for the bill’s pop­u­lar­i­ty. Nobody could defend that. In a real free mar­ket sense, that should be fine. If 24 mil­lion peo­ple elect’ to not buy insur­ance, who are we to say that that is a prob­lem?” Nobody real­ly thinks that way out­side of a very nar­row spec­trum of zany and cold-heart­ed lib­er­tar­i­ans. I agree. I think there has been an implic­it, pro­gres­sive accep­tance of the notion that the fed­er­al gov­ern­ment, or the gov­ern­ment, should insure that every­body has access to health­care. That is one good thing that has cer­tain­ly been happening.

Sarah: On that note, how do peo­ple stop this thing from pro­ceed­ing through the Senate?

Adam: Well, I think that, first of all, we have to stop it. Even those of us that believe that we need to go well beyond the Afford­able Care Act should absolute­ly rec­og­nize the harm that this would do, the deaths that it would cause. A lot of peo­ple have put out esti­mates of poten­tial deaths that could result in some­thing like this. I throw out a num­ber in my recent Guardian piece of around 24,000 peo­ple a year if 24 mil­lion peo­ple lose their health insur­ance. So, lives are on the line. Suf­fer­ing will increase. We have to stop it. It is an all hands on deck approach. I think every sen­a­tor has to be pick­et­ed, tar­get­ed. I think that they should know that if they vote for this that they are going to face the full wrath of the cit­i­zen­ry. I think the more protests, the more activism around this in the very short-term, the better.

It is obvi­ous­ly going to play out one way or the oth­er very soon. The Trump­care bat­tle is a short-term fight in that if they don’t get this through soon, and they need to use rec­on­cil­i­a­tion to get it passed, it is dead.

Sarah: Explain rec­on­cil­i­a­tion. We touched on that talk­ing about the ACA, but for peo­ple who don’t under­stand how that process works …

Adam: In gen­er­al, a fil­i­buster in the Sen­ate means that you need to have 60 votes to over­come it. There’s going to be no Democ­rats went along with the health­care bill, the Trump­care, as far as we know. In order to get around the 60-vote require­ment, there is a pro­vi­sion of rec­on­cil­i­a­tion that allows bills that have a pre­dom­i­nant­ly bud­getary impact to be passed with a sim­ple major­i­ty. There is a time­line for that. It has to be done rel­a­tive­ly soon.

There is actu­al­ly some ques­tion whether some pro­vi­sions in the House bill would even be allowed to be passed through rec­on­cil­i­a­tion. There is some­thing called the Byrd Rule that describes what sorts of things are allowed to be includ­ed. We don’t even know if the House bill in its cur­rent form could actu­al­ly be passed as rec­on­cil­i­a­tion, but regard­less, if they want to pass any­thing, it is going to have to be through rec­on­cil­i­a­tion because unless they real­ly come to the cen­ter in some way, they are not going to get enough Demo­c­ra­t­ic sen­a­tors to go along. Or, any Demo­c­ra­t­ic sen­a­tors to come along to hit 60 votes.

Sarah: You have been part of the fight for sin­gle-pay­er for quite a long time now. Talk about where you think that fight is and why it is impor­tant to keep it up even as we are try­ing to stop the health­care apoc­a­lypse here.

Adam: It is crit­i­cal because the sta­tus quo is very unjust. Think of it this way, Trump­care is going to increase the num­ber of unin­sured by 24 mil­lion. But, in 2016, accord­ing to the Nation­al Health Inter­view Sur­vey, there was still 28 mil­lion peo­ple unin­sured today. Then, there are even more peo­ple than that who are under­in­sured who are, again, hav­ing high co-pay­ments, high deductibles, unable to go to the doc­tor, unable to fill pre­scrip­tions. The sta­tus quo is bad and peo­ple are suf­fer­ing. As long as that is the case, we are going to keep the door open to right-wing attacks. Always. There will always be a right-wing eco­nom­ic pop­ulist like Trump who is going to say they will make health­care bet­ter. Well, we are open­ing the door to that if we don’t do some­thing about it.

It is crit­i­cal that we keep the fight going for a bet­ter tomor­row, for a bet­ter future of health­care, and not just rear-guard defen­sive bat­tles of keep­ing things the way they are. The real­i­ty is that peo­ple are not hap­py with the way things are today. It is not good enough. The counter argu­ment might be, Well, what is the like­li­hood? Are we ever going to get sin­gle-pay­er passed under this cur­rent gov­ern­ment?” No, we are not. But we could under the next gov­ern­ment. This is the time when we coa­lesce. This is the time when we put togeth­er our argu­ments, we put togeth­er our coali­tions, when we begin to turn sen­a­tors and rep­re­sen­ta­tives to sin­gle-pay­er so that when the polit­i­cal tide turns, we can see this hap­pen. We need the grass­roots armies in place now to do that.

Sarah: How can peo­ple be part of those grass­roots armies? Where can they get involved with health­care organizing?

Adam: There are so many dif­fer­ent orga­ni­za­tions out there that are doing sin­gle-pay­er work. My orga­ni­za­tion is Physi­cians for a Nation­al Health Pro­gram. It is cen­tered around med­ical pro­fes­sion­als, although we cer­tain­ly have oth­er mem­bers as well. There is Health­care Now. There are var­i­ous labor orga­ni­za­tions who are very involved in this. Nation­al Nurs­es Unit­ed, which is the largest nurs­es’ union in the coun­try is very much behind sin­gle-pay­er. I think it depends on where you are and what sort of work you want to do, if you want to get involved in a group that is maybe affil­i­at­ed with your pro­fes­sion or not. There are a host of groups out there under some­thing called the Coali­tion for Guar­an­teed Health­care that is a coali­tion of dif­fer­ent groups. You can go to that web­site and see some of those groups. There is lots of activism on this issue.

I think, yet, from a larg­er per­spec­tive, health­care activism can real­ly be a crit­i­cal pil­lar of the left mov­ing for­ward. I think it is an issue that does bring peo­ple togeth­er. I think it is an issue that has res­o­nance with the gen­er­al pop­u­la­tion. A Gallup poll from last year finds 58 per­cent sup­port among the gen­er­al pub­lic for sin­gle-pay­er. I think this is a good cause that could help gal­va­nize ener­gy on the left. Obvi­ous­ly, there are many oth­er cam­paigns we need to be fight­ing and work­ing towards. I am not sug­gest­ing this be the pri­ma­ry, but I think it could be a real­ly gal­va­niz­ing move­ment and cam­paign on the broad­er left struggle.

Sarah: How can peo­ple keep up with you and your work?

Adam: Well, like some oth­er peo­ple, I am on Twit­ter @awgaffney and I have a web­site www​.the​p​ro​gres​sive​physi​cian​.net. I would also send peo­ple to my organization’s web­site which is www​.pnhp​.org. It has some great resources on sin­gle-pay­er, on the pol­i­cy issues behind it so that we can real­ly mount our most effec­tive argu­ments. Those sorts of resources can be very help­ful for that.

Inter­views for Resis­tance is a project of Sarah Jaffe, with assis­tance from Lau­ra Feuille­bois and sup­port from the Nation Insti­tute. It is also avail­able as a pod­cast on iTunes. Not to be reprint­ed with­out permission. 

Sarah Jaffe is a for­mer staff writer at In These Times and author of Nec­es­sary Trou­ble: Amer­i­cans in Revolt , which Robin D.G. Kel­ley called The most com­pelling social and polit­i­cal por­trait of our age.” You can fol­low her on Twit­ter @sarahljaffe.
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