“A political struggle is in its essence a struggle of interests and forces, not of arguments.” —Trotsky, Revolution Betrayed
Firing the opening shot in his new offensive in the battle for single-payer, Bernie Sanders presented his open-and-shut case in a New York Times Op-Ed piece:
“Do we, as a nation, join the rest of the industrialized world and guarantee comprehensive healthcare to every person as a human right? Or do we maintain a system that is enormously expensive, wasteful and bureaucratic, and is designed to maximize profits for big insurance companies, the pharmaceutical industry, Wall Street and medical equipment suppliers?”
Although every sector of the capitalist economy without exception can be described as “enormously expensive, wasteful and bureaucratic, and designed to maximize profits for big [companies and] Wall Street,” the US healthcare crisis is unrivalled in its glaring absurdity as an expression of capitalism’s historical impasse. With annual revenues of $3.3 trillion, the healthcare industry accounts for nearly a fifth of US GDP.
Seven years after Obamacare was supposed to have solved the problem, some 30 million  people are still without insurance and face financial ruin if their health takes a turn for the worse—over 60% of bankruptcies  are caused by medical expenses. Over 5.6 million needed medical care in 2016 but had to forego it because they couldn’t afford it. Half of the $2 billion raised by the crowdsource site GoFundMe last year went towards efforts to cover people’s healthcare expenses. One study  estimated that 45,000 deaths each year, or 123 per day, are the direct result of lack of coverage.
The single-payer movement’s fierce and energetic base of committed activists is driven in no small part by the horrific reality that people are losing their lives every day—not because of the limits of medical science or technique—but because it would reduce or eliminate the profits of health insurance companies to save their lives.
Battle lines being drawn
It therefore comes as no surprise that the life-or-death battle for universal health care is working its way to the forefront of the class struggle in the US, as a majority of Americans are warming up to the once radical-seeming idea of liquidating the private health insurance market in favor of centralizing and streamlining the function of guaranteeing health care coverage in the hands of the state.
A June poll  by Pew Research found that 60% of American—and 67% of those under 30—feel the federal government should be “responsible for ensuring universal health care coverage.” A more precisely worded poll  by Kaiser Health Tracking conducted in the same month found that 53%—including even 24% of Republicans!—favor a national health plan in which all Americans would get their insurance from a single government plan.
Meanwhile, the grassroots forces on the ground pushing for single-payer have gathered steam , growing to hundreds of organizations with membership in the millions, joined most recently by the Democratic Socialists of America’s robust network of activists spanning all corners of the country. Following a decision to prioritize the battle for single payer at its Chicago convention this summer, DSA’s commitment to deploy its energetic door-knocking, phone-banking, and canvassing foot soldiers opens the potential to step up this fight even further.
Perhaps more importantly, it also means that socialists, union members, and activists across the country are actively discussing, strategizing, and debating the route to single-payer victory—the tasks before us, and the obstacles that stand in the way.
As revolutionary socialists we are fighting for health care for all, not health insurance for all. Most Americans are not yet clear on the significant difference between these two proposals, and most single-payer campaigns aren’t explicit about it either. So let’s be clear: We fight for a single-payer system in which the insurance industry is abolished, the health care provision sector is nationalized, and the state pays for and provides universal health care, not a single-payer system in which the state merely pays for—i.e., subsidizes—private health providers.
What will it take?
Socialists have a critical role to play in providing the movement for single-payer with the unwavering backbone that only a class-struggle outlook can provide. Never mind the fact sheets and talking points, it is the most basic capitalist class interests—not a deficiency of persuasive data—that has stood in the way of implementing what millions now consider a no-brainer reform.
To begin, we are faced with the task of prying a highly profitable, multi-trillion-dollar market from the grip of the capitalist class. In the rest of the “industrialized world”—which Sanders invites the US to join—it was not through the gracious civility of the capitalists that this reform was granted, nor through the initiative of liberal capitalist parties. It was a hard-won concession forced on the capitalists with the threat of revolution, achieved through massive mobilization and old-fashioned class struggle, led by labor and the socialist and communist parties of the working class.
But unlike the major bankrupt industries that were nationalized in postwar Britain at the time the National Health Service was set up, US health insurance is a booming industry which just last year increased its income by 46%, netting $13.1 billion in pure profit. Not only is the health insurance industry parasitically enmeshed throughout the broader health care sector, its tentacles are also intertwined with the nerves and tissues of the Democratic Party, which received over $15 million in “donations” from the insurance industry last year.
Faced with such a serious battle, the leading voices of the single-payer movement could do no greater disservice than to lull their troops into a false anticipation of an easy legislative victory. Removing this parasite will require, not so much a delicate surgery, but a battle to the death against a monstrous hydra and the entrenched political forces it controls.
Single-payer is by no means beyond reach—on the contrary—this demand clearly has the potential to become a galvanizing force for the labor movement. But the political path to victory is not through the Democratic Party, which serves at the pleasure of the markets, but in the creation of a mass socialist party of the working class, which, not coincidentally, is another common denominator in the rest of the so-called “industrialized world.”
A litmus test?
Even if the entire Democratic Party were to come on board, it’s no secret that Bernie’s Medicare For All bill has no chance of passing this Congress, controlled as it is by a Republican majority. Sanders has acknowledged  as much, saying that the point of the bill is to “force a conversation.” This fact should figure into our strategic considerations. Spotting a golden opportunity to win “progressive” points without threatening their generous friends in the insurance industry, over half of House Democrats and 16 in the Senate have been more than happy to join Bernie’s “conversation”—several of them with an eye on the 2020 presidential primaries.
Some have argued  that this indicates a growing momentum of the “progressive wing” of the party and that, if supporting single-payer is upheld as a “litmus test” for progressive candidates, the Democrats really can be pushed to the left. However, to fall into this trap would be more than a disastrous waste of time, energy, and momentum—it would effectively derail and disorient the movement, as was shown this summer in California.
Originally drafted and championed by the California Nurses Association, the Healthy California Act was a legislative bill for a statewide single-payer system that had previously made it through the state legislature twice, only to be vetoed by Republican Governor Schwarzenegger. When the Democrats captured California’s House, Senate, and governorship, single-payer activists were confident that they had it in the bag. A massive campaign involving 350 community and labor organizations and millions of volunteers mobilized support for the initiative across a state in which 70% of the population supports single-payer. Three weeks after it passed the state Senate, the bill was killed by the leader of the State Assembly, Democrat Anthony Rendon, arguing that the funding provisions were not clear.
Leaving aside the fact that Rendon himself received $150,000 from insurance and pharmaceutical companies, the episode is a clear example of the party’s priorities. When they had full control of the US Congress in 2009, it was Democrats—not Republicans—that blocked every attempt by Sanders, who should know better by now, to push Obamacare to the left by introducing language to expand Medicare or to allow the government to negotiate drug prices. We must learn the lessons of history or be forever condemned to defeat!
Who will pay?
The near-miss in California also foreshadows the maneuvres that Democrats will inevitably execute against any single-payer legislation that comes within range of success: present the funding issue as proof of a poorly thought out initiative, or resort to dubious inflated figures to argue its infeasibility. In doing so, they are merely regurgitating the talking points of the insurance lobby: it’s unaffordable, it will cost trillions, savings on health costs will be cancelled out by increased taxation, etc.
These obstacles can only be swept aside by socialist arguments and a class-based program. If the capitalist politicians argue that something as basic as universal healthcare is not feasible within the limits of the system in the richest country on earth, we’ll be there to take those arguments to their revolutionary conclusion—by pointing out that capitalism is the root of the problem. Since the Democrats are in bed with the health insurance hydra, our task is to put all our strength towards the creation of a genuine mass political vehicle for our class—one that will allow us, by degrees, to wrest all capital from the capitalists, starting with the health insurance companies.
Does this mean postponing the fight for universal health care until we’ve built a new party? Not at all! It means arming ourselves to conduct this fight all the more consistently and implacably without political concessions or compromises, while soberly preparing for the challenges that lie ahead.
Neither the founding of a mass socialist party nor the abolition of the insurance sector and the nationalization of healthcare providers will be walks in the park. But socialists specialize in preparing the future and altering the course of history, not bemoaning the immensity of the task, or settling for what we are told is “practical.” Besides, along with favoring single-payer, a record  61% of Americans now say they want a third major party, and socialists are in a perfect position to tie these strings together!
Given the discontent in society, a mass independent political force would spread like wildfire throughout the country once it emerges and establishes its viability. The demand for single-payer could be placed at the top of the agenda—complete with crystal-clear funding provisions.
The combined assets of the life and health insurance industries amount to nearly one-third of US GDP at a staggering $6.8 trillion. By seizing the assets of these parasitic profiteers, without compensation, as well as nationalizing and integrating all the insurance, medical equipment, and pharmaceutical companies, along with the hospital networks and clinics, into a single democratically administered health provider, not only would the cost of care be dramatically reduced, it would also be drastically simplified. A socialized national healthcare system would dispense with the monstrous bureaucracy and waste that doesn’t cover everyone and still costs 83% more per capita than the Canadian universal system, and double the cost of the British NHS.
In his appeal, Sanders elaborated further: “We remain the only major country on earth that allows chief executives and stockholders in the healthcare industry to get incredibly rich, while tens of millions of people suffer because they can’t get the health care they need. This is not what the United States should be about.”
But as any socialist will point out, this is precisely what US and every other capitalism is about. That’s the problem. It is precisely the irresistible logic of taking the fight for universal health care to the end that makes this seemingly “common sense” reform such a threat to the capitalists. If it is acknowledged that it makes no sense for a small minority to profit off the health and sickness of millions when the resources exist to provide treatment and care to all, what other conclusions will people begin to draw about this society? Why have a small minority of chief executives and stockholders enrich themselves at the expense of our access to education? Why allow real estate magnates to speculate on the housing market while 11 million workers are forced to spend half of their income or more to cover rent? Why should food production be organized according to the profit motive while there are people starving and undernourished?
The idea that we need a democratic plan for the entire economy could become very popular very quickly—because it’s an idea whose time has come. If socialists can bring a revolutionary socialist program into the multi-millioned ranks of single-payer activism, a genuine victory on this front and many others will be within reach, not only for US workers but for the workers of the entire world.