This can all feel like so much. It feels like so much to me! I sit to read or write and the waves batter me and my body feels like a towel, wet and crumpled on the floor; I fall inside myself and wish for some angelic comet to plunge into my house and gently, quietly lift us all from this national suffering. But I don’t think that’s fair of me to do. It’s not very kind to indulge in nihilism when other people have even more at stake. What do you do? How do you tilt against the grotesque squalor of the world?
My answer begins with single-payer. Single-payer won’t solve all of the problems we’ve talked about in the previous section of this book. It won’t even solve most of them: it won’t build the houses, it won’t feed the people, it won’t bring jobs or money back to rural areas. But that’s all right, in a sense— no program can, not all at once. What single-payer can do, I believe, is serve as a ladder we can climb, all together, into a better world. A properly designed single-payer program is one titanic step toward making people safe in their own homes, in their own bodies. It is a reprieve from our continual fucking-over by the structure and stricture of private insurance. And it is a method of finally demanding accountability from a state that permits (or even encourages) the sins that cause mass suffering—and the medical inequities they produce.
It’s not a hard sell. Single-payer isn’t that complicated (the real complicated shit is the various bureaucratic coping mechanisms invented to respond to the inadequacies of private insurance!) and most people like it already. More people will be drawn to it once they learn what it means and how it fits into the nooks and crannies of their lives. Most doctors and nurses like it, both because they’ve seen the devastating consequences of uninsurance among their patients and because they’d like to avoid the grating bureaucracy of trying to get paid by insurance companies.
The people who tend not to like single-payer are people who wouldn’t like anything that didn’t make them money: the insurance companies it would replace, plus the pharmaceutical, device, and hospital CEOs whose profits might be cut into by the rise of a larger, stronger, payer. Then there’s the powerful people who generally benefit from human suffering: the abusive boss who wants to make sure you can’t quit your job; the abusive husband who wants to make sure you can’t quit your relationship; the CEO who enjoys being able to cut benefits while knowing his workers can’t strike for fear of losing insurance; the lizardlike politicians who find it useful to first advance policies that let rich people plunder their districts, then blame poor people, people with disabilities, and people of color for the resulting scarcity.
These problems are not new in America. We’ve been suffering needlessly for generations. We continue this suffering because, at every conceivable opportunity, our politicians, our policy-makers, the CEOs who mine us for profit—have decided to pursue moderate, subdued, pragmatic, and useless policies. They have had every opportunity to help and have refused. They must be left behind. They’ve started coming out of the woodwork, and they’ll continue to do so for the next few years. They’ll have “responsible solutions” for “new American healthcare.” They’ll smile and go on TV and say they’re very concerned about all these problems whose structural causes they, personally, have benefited from. They will reach out to take our hands, tenderly and piously, and whisper, “This really is the best we can do right now,” as they jam them in the garbage disposal. So they’re out.
We will have to turn to each other.
What Hasn’t Worked
There’s a lot of history to learn from. The fight for single-payer (or, before any payers existed, universal healthcare) is not new—it’s been running in parallel with the development of the entire insurance industry. Beatrix Rebecca Hoffman, a historian of healthcare inequity and healthcare organizing, wrote a wonderful brief history called “Health Care Reform and Social Movements in the United States.” I recommend it; she demonstrates why our healthcare movements thus far have failed. I would prefer not to fail again.
For the past hundred years, health reform legislation has been in many cases the domain of well-meaning, well-intentioned insiders. But every time these insiders—the senators, the policy-writers, even the union or nonprofit leaders—have taken on the insurance industry, they have been beaten by a reactionary establishment (described, unflatteringly, above) that is capable of outmaneuvering, outfoxing, and outgunning health reform. The establishment has money and power, and if you come at them from within, they can swat you down. The policy insiders and think-tank presidents have learned that they can write a healthcare bill and wave it around to gin up support among the grass roots, but they have lost, over and over and over again.
They lost in the 1940s by “discourag[ing] rank-and-file initiatives” and “never consider[ing] grassroots mass mobilization.” They lost in the 1970s, when, despite working with civil rights and antipoverty groups, the universal healthcare bill was drowned out by 13 competing bills sponsored by industry and establishment organizations. They lost in the 1990s when the Clinton administration tried to assemble a huge, complicated series of public-private partnerships that would somehow try to keep everyone satisfied—except the grass roots, who either got confused by an incredibly dense policy or were ignored when they demanded more. The Patient Protection and Affordable Care Act of 2010 was lauded as a massive success by a subsection of liberal commentators in its time, but . . . if it were actually successful, I wouldn’t have to write this book.
Hoffman sees victory in healthcare reform coming from grassroots movements—she cites ACT UP as a prime example. ACT UP (AIDS Coalition to Unleash Power) is perhaps best known for their powerful, dramatic protests—throwing the ashes of their loved ones who had died from AIDS on the lawn of the White House. Here, in the relative comfort of 2019, it’s hard to remember how completely marginalized people with HIV/AIDS were in 1987. A sizable portion of the federal government actively ignored the epidemic, and explicit descriptions of it as a “plague from God” were tolerated, if not welcomed. ACT UP organized not just people with HIV/AIDS but formed coalitions with organizations of people of color, women, and people who use needle drugs (who were disproportionately likely to get HIV), and through years of collective effort forced mayors, presidents, and corporations to take action—and then, crucially, kept the pressure on after they got their initial goals.
I would additionally cite ADAPT as a powerful popular health movement in contemporary times. ADAPT is a coalition movement for rights for people with disabilities. The fights they have had to take on just to be treated like people are many, from transit access to home health to the current fight for the Disability Integration Act. You might know them as the reason Medicaid still exists as it does today. During Congress’s various ACA replacement debates, ADAPT protestors bused down to the Capitol and protested on the floor. They were arrested, their healthcare devices broken, and they were dragged screaming to police buses and hauled off to jail without care or concern for their medical needs. The next day, they came back—over and over and over again.
These grassroots movements have succeeded. While perhaps they haven’t succeeded as much as they’d like to—these are literally matters of life and death—they’ve done more than any think tank in all the East Coast. But they cannot win what they deserve—what we deserve—alone.
We have an obligation. We must not lose again. We stand on the shoulders of hundreds of thousands of nurses, of tens of thousands of doctors, in the legacy of grassroots movements like ADAPT and ACT UP—and we must build the massive popular movement that not only demands single-payer from our government, but demands health justice in our nation.
The bill we need does not yet exist. There are bills that are good, there are even good single-payer bills, and though I hope they pass, they are not and will never be sufficient in and of themselves. Any health justice movement that is satisfied by an existing bill, or that organizes around a bill, instead of around and among the people who are most immiserated, will follow its historical predecessors and fail. It has already failed.
So the answer is easy: skip the politicians and go to where the people are. Because the people need help. And we have to do it together.
What Will Work
Idaho hardly seems like the place for a health justice movement. It’s an overwhelmingly beautiful place that holds some of the dream of the American Western frontier: a place you can go to get away from everyone else and, among the mountains and the forests, have some peace of mind. It is not so much conservative as it is isolationist (though the line between the two has narrowed in the past few decades). Its one metropolitan area, Boise, accounts for a little under half the state’s population. The rest of the state sprawls northward, a composition of scenes of great beauty.
Amid this beauty there is, of course, deep and widespread suffering. Rural hospitals are particularly overwhelmed in Idaho, as a shriveling safety-net program saddles them with high costs and a mostly uninsured population. Some of them close. After the passage of the ACA the Idaho legislature refused to expand Medicaid for various reasons: a weak governor, a coalition of far-right politicians, general Democratic reluctance. Then, in November 2018, a ballot measure to expand Medicaid in the state passed. And not by a little—with a 61 percent majority. It passed in four-fifths of the counties, not just in the urban areas. There was no “blue wave” in the state—the Democratic candidate for governor lost by 22 points.
Medicaid expansion in Idaho took a form virtually unseen in contemporary America—or, at least, the America that matters to the pundit class. It was a popular movement built by constant, diligent labor: a hundred meetings, a thousand canvasses, a hundred thousand handshakes.
I spend a lot of time exploring the mass immiseration of people in America. I take a lot of steps in the shadows of the cruel and opulent machine. So I often seek a chalice to bear, and in Idaho I glimpsed a small and powerful hope.
The movement started when the northern Idaho ski town of Sandpoint refused to pass a tax to fund its schools. Idaho schools are notoriously underfunded after a decade of property tax decreases and education spending cuts. Three friends— Emily Strizich, her husband, Garrett Strizich, and Luke Mayville—had enough and decided to run a citizen campaign to pass a lien to keep their schools funded. It succeeded.
The movement grew. They called themselves Reclaim Idaho and, after driving around talking to people, they set their sights on Medicaid. Reclaim Idaho bought an RV, painted it green, and decided to keep driving—all across the state, talking to literally anyone they could. They found people who knew their communities and who would volunteer to organize them.
Then they kept driving.
From this patchwork campaign Reclaim Idaho became a bona fide DIY statewide movement. While the three core Reclaimers coordinated resources across the state and put together hundreds of events, local organizers were generally trusted to organize their areas as they saw fit. Which they did: thousands of volunteers knocked, texted, and called hundreds of thousands of people.
Events in virtually every county of the state brought elected officials, doctors, people without insurance, and other citizens together to talk about Medicaid. The proposition got on the ballot with plenty of room to spare and not much money spent. The creaky state Democratic party alternately shied away from and then glommed onto the movement, depending on whether they thought it would poll well. The Reclaim Idaho volunteers I met spoke of kindness, of fairness, and of economy. They went to their neighbors in urban areas, in rural ones, in trailer parks, in the sticks, in gas stations and grocery stores and college campuses. They spoke about how Medicaid expansion was free federal money to help people who are suffering, which would then be invested in Idaho’s medical workers. They shared stories of making too much money to qualify for Medicaid and falling in the gap, they talked about rural hospitals that couldn’t afford to treat their uninsured patients, they talked about the parts of Idaho that were ravaged by uninsurance. They talked about justice.
And then the people turned out to vote and extended the basic decency of healthcare to their neighbors.
The three Reclaim Idaho founders insist that this was not their movement alone. It was a campaign they coordinated, but it was funded and powered by normal people trying to pitch in and help, a banner carried by thousands of volunteers every single day until the last minute, a thousand torches held aloft in a great and spectacular line from the forest to the mountains. I watched a Reclaim volunteer run into a small dive bar and canvass everyone there with about 15 minutes before polls closed. He succeeded and escorted one young voter to the polling station two blocks away. “I didn’t want to leave anything on the table,” he told me.
And the whole thing was so damn wholesome. I saw grandparents, grandchildren, friends, neighbors, and kids—everyone working together to feed each other, take care of each other, nourish and support each other, as they all sought to reach out and find new people to speak with. Like many folks my age, I’ve kind of self-atomized: I’ve never been close with my family; I’m never having kids; I move from city to city like a traveling circus. I like the family I have constructed for myself. But it really does feel special, safe, and nourishing to watch an extended community-family take care of itself. It is the self-regenerating model by which a larger one can be, slowly, and with difficulty, constructed.
There were but minutes between the news that Medicaid expansion had passed and vows from Republican lawmakers that they’d find a way to gut it, or attach work requirements. This would not be permitted. Reclaim Idaho mobilized the same people who came out to pass the bill, and they defended it—calling drives, rallies, protests. Candidates who did not win in November came out to train volunteers to effectively petition their representatives. There were more potlucks, more cookouts, more movements. In January 2019, Idaho Proposition 2 was signed into law. In February, the state submitted a Medicaid expansion request to CMS.
I insist that this is the model—this is the only model—by which health justice can ever be realized in America. Lovingly, devoutly, and diligently—an organized, focused, and trusting movement building community for those who have most been harmed—borne from the specific furies of love. All your lightning waits inside you.
We must extend the basic decency of “showing up”—going to the people around us, listening, asking questions, finding common ground, and putting our shoulders to the wheel. We must identify what battles we can win, and then win them. We must provide material relief for the people around us who are suffering now.
We must fight in our homes for a continuous spectrum of demands aimed toward health justice. Unlike liberal policy-tweak incrementalism, our successes must be material and redistributive reforms. We must bring to the front our neighbors and friends who have been made to suffer most cruelly, and we must demand that the crowns of thorns thrust down upon their heads are lifted. We cannot rest until they are liberated from the suffering inflicted upon them.
We don’t have to start from scratch. People have been fighting injustice much longer than any of us have been alive. We just have to show up.
In San Francisco, a coalition won Prop F, the right to counsel for people who are evicted. In Maine, the Maine People’s Alliance won a significant minimum-wage campaign at the ballot box in 2016. They then turned out their volunteer base for the minimum-wage campaign to collect signatures to put Medicaid expansion on the ballot—which they did, very quickly, and then won again in 2017. In San Antonio, the movement for paid sick leave collected 144,000 signatures—40 percent more than the number of people who voted for mayor in the previous election, making it the largest popular movement in San Antonio in years, if not decades. A couple hours north, in Austin, where barely anybody can afford to live anymore, a coalition of grassroots activists won a $250 million affordable housing bond at the ballot—more than twice the sum of every other housing bond in city history.
There are setbacks. Each of these victories can be waylaid by a malicious politician and, in some cases, are currently under assault. But I think these victories are building blocks. If we give people something material, they will fight to keep it. If we fight with people today, they will fight with us tomorrow. We build solidarity so that we can build power. Our job is not to build one massive popular movement. It is to stitch together a popular movement—a big, messy quilt of movements for health justice at home, spanning the country from coast to coast and plains to gulf.
This is all to say that the work of health justice is not siloed. Housing work, healthcare work, anti-carceral work, disability liberation—all share health equity in their articulations of a better world. This and only this, I think, can bring about single-payer, and, beyond it, health justice. We have seen that movements for universal healthcare that are led from the top down have not succeeded.
Yet through this massive mobilization—and only through this massive mobilization—this is a fight we will win. Single-payer is already a wildly popular idea among the people it affects. This is not a radical proposition. We are simply discussing a basic principle of fairness.
After all, we all come from nothing. We are all fashioned from a formless and shapeless place. We have been thrust through the maw and born into a world that is arbitrary and unequal in its allocation of suffering. And yet instead of affording each other the basic dignities of being human, we have developed this bizarre system of American health in which one’s suffering is one’s own responsibility, in which empathy is vestigial and unnecessary. We have atomized suffering and, in turn, assigned blame for suffering to the people who suffer it.
I have seen such naked suffering inflicted in my American name. I have seen neighborhoods ripped apart by the unrepentant, unyielding bloodlust of capitalism. I have seen families torn limb from limb in the service of extracting profit. I have seen the dehumanizing machine all at once and felt despair. For me it is heinous to feel complicit, through my simple existence in my only and horrible home, in the mass immiseration and annihilation of those against whom the whole rotten weight of the world is stacked.
This is intolerable to me. I hope it is to you, too. And so I hope you join me in saying: enough.
Not in our name may this America persist. May we root ourselves not in fear but in love—love for those who suffer around us, as we, too, will one day suffer—and from that love, may we cultivate the fury by which this cruel machine can be destroyed.
My friends—single-payer is moral. Single-payer is necessary. Single-payer is achievable. Solidarity now, solidarity forever.