Organizing for health care from the bottom up
Last summer, the Republican drive to "repeal and replace" the Affordable Care Act (ACA), also known as Obamacare, collapsed when several GOP senators defected. Key to this narrow victory was pressure from grassroots actions and protests in Washington and around the country, which dramatized the overwhelming opposition to Trumpcare.
Since then, the Trump administration has continued to undermine and hollow out the ACA system, though at least the all-out assault, including the wholesale destruction of the Medicaid health care program for the poor was headed off for now. But all the weaknesses of the ACA--which was actually adapted from a state-level program put in place by Republican Mitt Romney while he was governor of Massachusetts--are being pushed to the breaking point. That's one of the factors driving greater support for a Medicare-for-all system--often referred to as single-payer because health care coverage would be covered by a single, state-run entity--including Bernie Sanders' proposed legislation in the Senate.
Dr. Roona Ray is a chapter fellow of Physicians for a National Health Program (PNHP) in New York City and a participant in the protests last spring and summer to derail the Republicans' Trumpcare agenda. She described to , a member of the New York State Nurses Association and fellow single-payer activist, about how that struggle played out and how it contributed to the ongoing effort to put forward Medicare-for-all proposals.
YOU WERE around when the Affordable Care Act was being created debated and ultimately implemented. What was that experience like for someone who was an early supporter for single-payer?
I WAS a medical student in Massachusetts when Romneycare began, so I was present for some of the politics that led up to the passage of that. I saw that taken to the national scale when so-called Obamacare, or the ACA, got implemented.
Obviously, it's exciting that people are talking about expanding access to health care, because it's a scourge on this country that so many people have been historically uninsured. But it has also been frustrating for me to see people who are progressive health advocates embracing a market-based system to solving or addressing the health care crisis.
Market-based approaches make things far more complicated than they have to be and don't solve the problem. We still have lots of uninsured and underinsured people in this country. We have people who are getting ripped off and their illnesses are getting worse because the health industry is profiting off of their health and disease.
It's frustrating for me that health advocates sometimes felt like they couldn't say that we want a goal of a single-payer system that covers everybody. They felt like they had to throw that under the bus in order to get the ACA. I wish we had stronger commitment on the left to our ideals and values.
AS PEOPLE started to experience the reality of the Affordable Care Act, some of the problems you identified started getting exposed. But then different forces tried to make explanations for the nature of those problems, how extensive they are and how to explain them to the public. What was your approach?
WHEN ROMNEYCARE was implemented in Massachusetts, right away, I saw that there weren't enough primary care doctors in the state to meet the demands that all these newly insured people were putting on the system. Practices had waiting lists for people trying to get in.
That was the first time I started to understand that there isn't any sort of central planning to how health services are distributed in this country. There's not really anyone thinking comprehensively about what people's needs are.
A needs-based approach to health care and politics is not some fuzzy, Pollyanna idea. It's quantitative; based in science, statistics and epidemiology; and grounded in a moral and political commitment to providing health care for all. It would involve planning medical education, training specialists and primary care providers, and distributing health care workers by epidemiology and medical need. It would include free education.
The ACA only further demonstrated that using the market as the only driver of meeting health needs doesn't work.
WHEN TRUMPCARE was first being proposed, people seemed acutely aware that it was a wholesale attack on millions of people's access to health care. How did you see that dynamic develop among individual activists as people joined this fight?
THE FIGHT around Trumpcare was really exciting because it mobilized lots of people who identified as patients, and everyone is a patient at some point. I would say that most of the people I spent the summer protesting with were people with chronic illnesses, people who were disabled, people who had family or friends who were directly affected, or people who were on Medicaid, but not necessarily with a chronic illness.
Health care affects people on a daily basis, so I think the threat that Trump posed with this bill is something people understood would affect them immediately. It wasn't just an idea or an ideological thing, so they mobilized, and it was really exciting to meet people who were outraged and take action with them.
ONE OF the slogans that have come out of this moment since Trump was elected is the idea that you can't fight the right from the middle. When Trump says "Make America great again", if your response is "America is already great," as Hillary Clinton and the Democrats did during the election campaign, that's not going to resonate with people. How did you see some of those ideas manifest themselves inside this emerging group of health-care activists?
I SAW for the first time this summer a broad use of the idea of Medicare for All, universal public health care and single-payer. I think that with these threats to health care, people suddenly have a sense that they should have a right to health care.
Not fighting the right from the middle is something that I'm excited to see manifest. I think we want to fight the right, not from the middle, but from a place of human need, and in my experience, that is inherently the principled left position. Human needs are how we should organize our society and the terms with which we should discuss politics.
Again, I think that what was most exciting for me was seeing patients coming out and talking about what their needs are as the bottom line. So it's not just a wonky policy discussion or something that can be compromised on. I hope politics are turning more toward being a question of human needs in the health care world and in the world at large.
LET ME ask you more specifics about this summer. What were some of the organized forces that came together, and how were some of the unorganized forces brought in?
BACK IN mid-June, I got an e-mail for a phone call that was happening to plan for a sit-in and an arrest action being planned for the following week in Washington, D.C., to protest the first version of Trumpcare that came out.
There were maybe eight or 10 people on the call, and I thought it'd be a small action. But when I showed up, there were about 80 people there, and 40 got arrested. I was surprised to see they came from all across the country. There were groups from Vermont, Arkansas and New York.
Some of the people who organized that first call were from the Center for Popular Democracy, which is an organization based in New York, but has offices and affiliates around the country. Others were from Housing Works, which is a long-time AIDS activist organization.
It seems like a lot of people who got connected to the organizing were patients who heard about what the Republicans were planning and were really upset. They weren't necessarily people who had done a lot of health care activism previously.
Of course, ADAPT was a force. They're a disability rights organization with a history of doing a lot of direct actions that organize disabled people to confront power and powerful people who are threatening their rights. In New York City, they have a history of doing a lot of direct action to expand resources under the Americans with Disabilities Act, and beyond it. ADAPT got mobilized around the Trumpcare issues because a lot of people with disabilities rely on Medicaid.
That's a sign of a healthy movement that there are lots of people and organizations involved with different perspectives, but similar values--not always exactly the same values and sometimes in conflict.
After the first action I was involved in where 40 people got arrested, within the next three weeks, there were two more arrest actions organized by the same groups, plus a couple other actions organized by other groups such as Democracy Rising and National Nurses United. All of them were in Washington.
Of course, not everyone got arrested. A lot of people just showed up and supported. This was a moment where a lot of people and organizations were forming new alliances and new relationships, as well as building on old relationships from years of previous organizing.
TAKE US through the trajectory of the summer.
WE DIDN'T know what to expect--no one did. June 28 was the first action that I was involved in, and we defeated the first bill in the Senate. This pattern kept happening: We would have an action challenging the latest version of Trumpcare being pushed at the time, and it would fail or the Republicans would decide not to bring it to a vote because they sensed they wouldn't win. Then they would come up with a new version.
Eventually, we started calling it the Zombie Death Bill, because they kept trying to bring it back from the dead. With each new zombie version of the bill, the same group of people, with larger and larger alliances, would organize for the next action--sometimes with less than a week to organize.
The first action I was involved in at the end of June had about 80 people and 40 got arrested. Less than two weeks later, there was another one where about 150 or 160 people involved, and about 80 people got arrested. And in between, there was a couple other big civil disobedience actions by other organizations where people were getting arrested.
This was making national news. I was very surprised when our first protest got on the front page of the USA Today. The photos were very dramatic. ADAPT started its actions where they were doing civil disobedience, and police were dragging them out of wheelchairs.
Later in July, I was part of an action in which probably about 500 people were involved, doing civil disobedience in all of the Republican senators' offices. I think about 280 people got arrested. That was one of the most effective actions I've been involved in, because the message we were sending was that we will be holding elected officials accountable.
While we were doing that in D.C., people were also planning actions in August back in the home districts of elected officials to challenge the logic of Trumpcare.
Also in July, I was part of a demonstration where about 20 people went into the Senate viewing galleries, which is usually a tourist destination, and we interrupted one of the votes on Trumpcare with chants and accusations of murder.
One of the things that I thought was most exciting in the middle of that was the pairing of the pro-single-payer language, the Medicare for All language, with the "defend the ACA" language. Activists I think picked up the "both/and..." approach very easily. They said we should both defend the principle of the ACA and expand it--expand the idea of health care for all. That was very heartening for me to see that.
WHAT DO you think are the possibilities and challenges of the ongoing collaboration within the movement to continue to shift the terrain towards fighting for Medicare for all?
I THINK the threats of Trump and Trumpcare have really galvanized the movement for single-payer, both federally and in the states.
It was after the summer of the constant threat of Trumpcare and the defeats of the attempted ACA repeal that Bernie released his Medicare for All bill. It's been exciting that we're putting forward new solutions that address some of the issues with the ACA--and more generally challenging the market-based approach with a needs-based approach.
The House bill for single-payer proposal has been there since 2003 and now has a majority of Democratic representatives on board. Single-payer is picking up a lot of steam and also recognition among the general public, so we now have this kind of friendly race between the federal and state bills.
People are mobilizing, both for federal change and at the state level, and I hope that single-payer will happen soon in either arena. This is going to be the litmus test--the hot-button issue in the 2018 elections across the country, and that's going to really catapult it into being a national priority.
The other thing that makes this a national priority is just how awful the health care system is. Every single person has a story about why the health care system is either difficult or destructive. I think there's greater consciousness that the system can't go on like this--that there's a lot of profits being made by the insurance, pharmaceutical and hospital industries at the expense of people's lives, and we need change very quickly.
WHAT DO you think explains the shift toward congressional support for single-payer? What does this say about the political moment and what challenges does it present?
FIRST , I have to say that as a doctor, it's frustrating that the health care crisis hasn't been more urgent, because patients that I've seen have lived unnecessarily difficult lives for a long, long time. We've needed significant change to the health system for years--decades, probably.
But that said, it's exciting that this is finally a national issue now. I think a lot has gone into making it a national issue that suddenly seems to be in reach, at least potentially. This is a big policy issue going into the 2020 presidential elections, and you can see Democrats trying to jockey to get their word in on single-payer, which is a pleasant change of pace.
What's caused it? I think some of it is what Bernie has done for the idea of single-payer specifically, as well as the more general ideas that he has brought to American politics: that human need should be the guiding force in politics.
In one of the debates when he was running for president, he discussed childcare policy at the national level, and that's something that I've never seen discussed as a national priority--but it should be. Childcare is something that so many people have to deal with, so it's something that's universal.
Sanders has brought basic human needs like health care and childcare legislation into the national spotlight and made them issues that the government has to grapple with in a more meaningful way than before.
Then, of course, there's the Trump effect: the explicit white supremacy that we're seeing and the really shameless grabs for money on behalf of the über-wealthy. I think that's really polarized the political discussion in a way that wasn't happening for many years when more neoliberal politicians dominated things with language that wasn't as incendiary.
It's unfortunate that this is how it's happening, but I really do hope and think that this will create a new politics in America. Certainly you see it in people who are in their 20s and early 30s--there's more consciousness of the fact that a system designed on profit doesn't work for so many parts of our society.
There's growing consciousness that we have to get that profit motive out of areas of human need, like health and education.
WHAT DO you think has kept the Democratic Party establishment inert on this topic?
THAT'S A similar question to your earlier one about why ACA advocates thought the market-based solution of the ACA would be the best solution to the health care crisis.
There's a combination of conflicts of interest, where the Democratic Party--and also a lot of the health policy experts who are linked to the Democratic Party--are heavily invested in or linked to the insurance industry, the pharmaceutical industry and the hospital industry. So a lot of the "best information" that comes out is biased toward what's best for these industries and not toward what's best for the public's health.
I think the other thing is probably a lack of imagination and experience in social change. I think you have to have some imagination that significant social change can happen, and also a good dose of hope and not fear. For a lot of the Democratic Party establishment, they have their funding sources, and they don't have much incentive to hope for a better society--and not many examples to follow either.
WHAT DO you think the Democrats' relationships to the health care industry represent? What role will they play in the movement?
I THINK the push for single-payer has to keep coming from patients and health care workers, who are the biggest advocates for single-payer. Nationally, one of the biggest advocates is National Nurses United, the big nurses' union.
That makes a lot of sense because health care workers see firsthand how much patients suffer, medically and financially, from the health system, and how the system makes working conditions unbearable and impossible for health care delivery. It's no coincidence that we're living in an epidemic of physician burnout while the health care industry is making record profits
I'm certainly not going to sit back and hope that the Democratic Party will lead the way. I think that there has to be constant organizing and pressure--that's what has made the issue come as far as it has.
Like the Democratic Party, the mainstream health policy world isn't inclined to trust the idea of single-payer. That attitude is seen as an "objective" response, but it's not necessarily--especially if the health policy experts are linked to the insurance industry.
WHAT DO you think are some of the different ways in which the movement can reach a younger, more multi-gendered, more multiracial and more politically left-wing audience?
THE GROUPS of people who have the most to gain from the single-payer system are those who have been historically most marginalized: people of color, women, immigrants--both documented and undocumented--rural people, queer people.
With the campaign around health care in New York right now, we're talking a lot about organizing in those communities. General political education is in a different place now, and there's a lot of discussion of intersectionality--we didn't have that language even five years ago as broadly as we do now.
There's a lot more consciousness among people that health and the health care system can impact people's lives really profoundly, especially in all these communities that have historically been marginalized. I think organizing in these communities is the kind of slow and steady approach that we need.
Transcription by Chris Beck and Jordan Weinstein