Democrats must pursue universal health care. They must also be smart about it.
Supporters need to be willing to take "yes" for an answer
One thing that the Republican push to take health insurance from more than 20 million people has done is to dispel the illusions of many moderate Democrats. "If the American Health Care Act passes," argues Vox's Erza Klein, "Medicare for all" will power the Democratic Party after 2017. This is almost certainly correct. In fact, universal public insurance will be the consensus Democratic goal whether the AHCA passes or not.
The idea that the structure of ObamaCare would insulate it from political pushback was always based on a lie: that national Republicans would support good universal coverage as long as the market was involved. This has never been true. The Heritage Plan that is sometimes erroneously cited as the basic model for the Affordable Care Act was in fact a plan to replace Medicaid, Medicare, and employer-provided insurance with private insurance that would cover very little. Not only was it nothing like the ACA, in other words, it was an even more radically right-wing plan than TrumpCare. And while the legislation signed by Mitt Romney in Massachusetts was actually similar to the ACA, laws passed by supermajorities of New England Democrats tell us absolutely nothing about what national Republicans support.
Whatever Republicans pretend to believe when it looks like Democrats might be able to pass something, the actual Republican response to the uninsured has always been "tough luck." The AHCA should stop the denial on this point, and make it clear that the Democrats should forget trying to pass legislation that Republicans can live with and just pass the best legislation they can, which means expanding public insurance as much as possible. There are a couple of implications related to this point.
First, supporters of universal health care need to be willing to take "yes" for an answer. Two potential Democratic nominees in 2020, Bernie Sanders and Kirsten Gillibrand, favored Medicare For All even before Obama was elected. This is definitely a point in their favor. But what is even more important is creating a norm in which every viable Democratic nominee is committed to universal public insurance. After all, a situation in which the president supports single-payer and 30 Democratic senators don't like it will not produce single-payer. The left of the party has always favored universal health care, but it's not enough. Major legislation requires a consensus.
If Congress is ever going to pass universal health care, or even take major steps in that direction, converts are going to be necessary. They should be accepted — and then held to their promises. Klein's reporting suggests that more and more moderates are realizing that market-based compromises were a sucker's bet, and this trend needs to continue.
Second, liberals should recognize that the Democratic Party is trending in this direction whether the AHCA passes or not. It might be tempting to interpret Klein's analysis as an argument for "heightening the contradictions" — that is, hoping the AHCA passes because it would make single payer more likely. But this would be a grave mistake.
The most important reason to go all-out to stop the AHCA is that the legislation would be a human rights catastrophe, creating enormous amounts of needless suffering, economic hardship, and unnecessary death. Maybe Democrats will be able to take over in 2020 and stop the worst from happening — but maybe they won't. And if Trump gets a couple more Supreme Court nominees confirmed, there's no guarantee that a Democratic fix won't be thrown out by the Court.
In addition, it's not necessary for the AHCA to pass the Senate for universal public insurance to become a consensus Democratic goal. The Medicaid expansion has been by far the most successful part of the ACA. The condition of the insurance exchanges, conversely, is likely to deteriorate even if the AHCA fails. The House passing the bill shows the true colors of the Republican Party, which should be enough.
And finally, in the short term it's unlikely that employer-provided insurance will be replaced with one fell swoop. Rather, the first major step will be to expand Medicaid and Medicare to cover as many people who don't get employer-provided or public insurance as possible, with an eye towards gradually moving more people who get insurance through work toward the public programs over time. Such expansions will be much easier, however, from the current baseline than from a Medicaid program that's been drastically cut. Passing the AHCA would mean that the next Democratic Congress has to focus on cleaning up the mess left by Republicans, and restoring funding would make the tax and spending increases to further expand Medicaid look more drastic. Leaving the ACA in place will make the move toward truly universal health care easier, not harder.
Whether it's straight single payer or — as I think is more likely — a hybrid system along the lines of France and Germany, universal health care should be the explicit Democratic goal, and I think it will be starting in 2020. The next fight in this war should be to save the Affordable Care Act and use it as the basis to keep pushing towards the ultimate goal of guaranteeing adequate public coverage for everyone.