Thinking outside the box on DSA’s Medicare for All strategy, part one

Note: There are plenty of good reasons why socialists should organize for single payer healthcare but what we lack is clear details on how we should organize and to what end. I am on the Medicare for All subcommittee of the National Political Committee. I plan to write a couple essays here exploring my thoughts on what those details might look like. This is the first, which simply asks pertinent questions and considers a few strategic and tactical positions. I am curious to read and hear other DSA member’s thoughts ahead of the NPC meeting in Chicago this weekend.

I want to win Medicare for All.

I’m absolutely not here for lifestyle socialism. I have deeply personal reasons to take back power for working and poor people.

To do that, we need to understand power as it exists and how to wrest control of it.

It’s not enough to say we’re going to win Medicare for All. Words aren’t magic. Without determining, substantively and definitively, who we would have to defeat, where we truly fit in the battle and how we’re going to develop a plan, “we’re gonna win” is no more than “Kony 2012,” a well-intentioned, well-hyped idea poorly executed because it never had a viable path to victory.

The presumed quickest path to Medicare for All is realignment of the Democrats. Force the issue on the Democratic Party by defeating anti-Single-payer Democrats in primaries and electing supportive Social Democrats (and perhaps a few Democratic Socialists to the House) in waves in 2018 and ’20. Take the House, the Senate and the Presidency. Do all this while holding politicians to account and avoiding the sort of destructive organizational infighting over single payer with much larger and more influential organizations like Planned Parenthood that is all but guaranteed to happen. Then, pass a bill that can survive being watered down. If the bill doesn’t pass, try to increase Congressional dominance in ’22. This all happens without an iota of Republican support while we organize in the face of what would likely be a trillion dollar coordinated corporate smear campaign.

Let’s start with a reasonable assumption: The Democrats will completely and utterly fuck this up.

We’ve already seen this. In California, they shelved single payer. In New York and Virginia, they co-opted it and sat on it. While the party seems to be coalescing around the idea, for the moment it seems more like wishful thinking than politically attainable policy. It’s very easy for politicians to say they’re for something when they know it’ll never happen and nobody can hold them accountable.

Let’s also make sure we put our influence over the party in the correct place. We do not control the levers of power. We don’t even have enough influence to hold those in power to account. While it is great that Sen. Cory Booker has cosponsored Sen. Bernie Sanders’ largely symbolic Medicare for All bill, make no mistake that Sen. Booker (and the rest of them) will turn heel at the faintest sign of trouble.

Worse yet, Democrats and their supporters have developed a tendency to internalize insidious neoliberal and even right wing ideology even when they hold power. In falling prey to that, they then begin grasping at the sort of bipartisanship that may make material conditions marginally better for some poor people but enormously better for the wealthy, thus further entrenching the system.

Even if the policy is successfully co-opted by the party, make no mistake: any “Medicare for All” bill passed in the next decade, under these conditions, would never be universal (abortion would be the first compromise, non-citizen residents would never be on the table), nor would it be without cost sharing (copayments, if not blunt means testing, would be the second compromise). From there, any number of disastrous concessions lurk around the corner.

All we have is the moral high ground, favorable polling and a substantively more just, probably cheaper policy position. As stupid as this is when you say those things out loud, it’s nowhere near enough to gain victory.

I’m not saying this to be pessimistic. I’m saying this because it is true, and we all know it. We have all seen it before. We can be thrilled (and I am!), as Tim Faust said in a recent DSA strategy call that “we are nearing the end of the prologue” for single payer, yet simultaneously be seriously concerned that canvassing for healthcare reform is a long shot for socialism, strategically.

Much of the current discussion within DSA focuses around canvassing, a single tactic, as though it were the program. We must be very careful to not elevate tactics to the level of strategy. Tactics must serve a strategy, or set of strategies, with agreed upon missions and definitions of success. In East Bay, the canvass was part of a campaign designed in service of a strategy developed by other organizations. As good tactics are meant to do, it succeeded in a few ways while it failed in others. Comrades who may have never worked in field organizing built on-the-ground skills in running canvasses, presumably built a substantial affinity database and it’s successfully become a differentiating wedge issue within California’s majority party. Yet the primary cause of passing actual single payer legislation failed for a variety of reasons beyond the control of the canvass organizers. More canvassing won’t address the reasons the bill stalled and move it forward again. As such, we should take a critical look at the current plan to export the tactic to other places. In campaigns, canvasses generally have specific goals. Who is the campaign’s target? What does canvassing do to upend existing power structures? How will the artifacts of canvassing (signatures, names, etc.) be used in future tactics? If the primary goal failed in California, why would it work in Wisconsin or North Carolina or in the U.S. Congress? Etc.

As you can probably tell, I’m skeptical of shoehorning single payer as a stand-in for DSA’s electoral strategy for the above reasons and a ton more that I’ll leave for another day.

We need a movement strategy, not an electoral strategy.

Let’s take a step back for a moment. Our mission as DSA is not to build Medicare for All. Our mission is socialism. In that context, winning Medicare for All is a potential tactic of the larger program of political revolution. In terms of healthcare, insurance is only a small hill ahead of the horizon we ought to set our sight upon. Insurance is only a piece of that healthcare puzzle. I don’t say this to minimize the massive amount of work involved in making this one thing a reality, but rather to more clearly maximize the difficult work ahead of us.

What we need, more than anything, is to reframe everything. Rather than think of Medicare for All as a singular path to creeping socialism, we should squarely set our sights on an ambitious utopian vision which happens to include healthcare as a human right. We must replace the existing cultural hegemony, not only on this issue, but on a great many issues of concern to us as socialists, with our own. We need to dominate the conversation, to reframe the terms of the healthcare debate and to, rather than seize existing levers of power, construct a wholly new power.

We do this by articulating a sweeping new vision to not only Democrats, but to as many existing social blocs as possible in as many social contexts we can imagine. We need society on our side, not only the same organizations perpetually in the Left’s orbit.

Victory for socialism depends on constructing a powerful movement that not only believes healthcare is a basic human right but can successfully drive socialist ideology into the mainstream. Every socialist program must be focused on building that movement.

Photo of the author holding a large fish.

Hegemony matters to create long term stability

Every winter I travel to Manitoba to go ice fishing for walleye on lake Winnipeg. To prove it, I’ve included a photo of me holding a fish. Our usual Canadian hosts are rural conservatives who are very active in conservative political organizing in Manitoba.

Over the years, while drinking and gambling with them in their garage late into the evening, I’ve had long conversations with them about politics.

Like many rural people left behind by an increasingly urbanized economy, they earn a living through multiple odd jobs and various creative side hustles. They have a few rough cabins on their property rented out to hunters and fishermen, rent out a room to a friend, and work several seasonal jobs doing dangerous work like breaking river ice (I kid you not that’s a real job).

Like many rural folks, they hold religious and cultural beliefs that I simply don’t share.

Like many conservatives, they hold political beliefs that I abhor.

What they can’t imagine, though, is a state in which their insurance is directly tied to their employer because they don’t have a singular employer. Taking away their healthcare coverage is just as bizarre to them as losing snow removal or running water to their home.

That said, these people are decidedly not socialists and no policy is going to trick them into believing what you and I do. Given a better alternative for themselves, they’d quickly abandon the policy and their communities, too.

This thought must come naturally to everyone in order to win Medicare for All: healthcare is a basic human right, a public good, not a commodity. The benefits of a healthier populace vastly outweigh the profit for a few small companies in the grand scheme of the economy. What is good for society is good for me. As a member of society, I should have a say as an individual.

That is also what we need to win socialism, the universal idea that self-interest and social interest are one and the same. That is a repeatable concept across any and all campaigns and tactics.

Determine our position

Identify strategic issues to address

There is already a lot of public support for single payer insurance, but is there enough support? How can we build solidarity with immigrant communities on this issue? With people of color? People struggling within a system don’t have the time or resources to fight the system, but the last thing socialists should do is replicate liberal white knighting. Yes, an ideal Medicare for All bill will materially help poor citizens of color and, if the policy includes residents, will materially help immigrants and refugees, but if we don’t build a broader base, we will never build a movement for socialism.

For what it’s worth, I make this same argument with mutual aid programs like the broken tail light clinics some chapters have taken up. There is a vast difference between giving shit away for free to people who may need it and using those programs to help people become active participants in their own liberation, either by outright joining our cause or by at least internalizing our shared values and paying them forward in their own lives and communities. Mutual aid programs should work not only on a specific cause like providing meals, but to intentionally build networks of continued and expanding mutual aid beyond the program itself. Constituency and community.

Beyond constituency and community, we need to understand the network of entrenched power and identify points of leverage, or at the very least, points in the system that we can realistically interrupt. A strategic analysis has to answer some difficult questions. Who are the targets we must defeat and who are our allies? What is our current ability, our capacity and our needs? Most importantly, what motivates these actors?

In order to win this fight, we have to destroy an economic institution in such a way that not only does the institution collapse but the ideology that created it is also fundamentally weakened. That institution, insurance companies and their allies, will do everything imaginable to protect their ideology. If we do not fundamentally convince our colleagues, families and our neighbors that private insurance is an alien concept, what are we doing, exactly?

From a socialist perspective, Medicare for All is one possible step toward the end goal. DSA shouldn’t be a canvassing army for other organizations focused entirely on single payer. It must be broader than that and far more visionary. We’re fighting an ideological war, not skirmishing with the Democratic party.

Strategically, then, we need to build a broad base. How do we do that? I ran for the NPC on some concrete ideas, some of which will be addressed in a followup essay, others will be brought up at the NPC meeting.

When we say that Medicare for All would liberate millions of workers who are dependent on their health insurance and would by virtue then help poor people and people of color, we ignore the tens of millions of them already on free healthcare programs who are not actually liberated.

I think the idea that winning Medicare for All automatically liberates poor people reverses the relationship we ought to orient ourselves toward when we’re organizing. Instead, we need to think about how poor people can liberate themselves through socialism and win Medicare for All along the way.

Our socialist vision — what sets us apart from run-of-the-mill progressives — gives us a framework through which we can recruit doctors and patients, nurses and the disabled unemployed, people of varying backgrounds around the idea that healthcare is a human right.

Threats and weaknesses

It’s important that we collectively think about the myriad external threats to Medicare for All and internal weaknesses in implementing a strategy. Here is a bit off the top of my head.

Money: The bad guys have more than us and always will. A considerable amount of our DSA efforts over the next 6 months will be spent on membership retention. Losing the inactive dues payers from Trump Bump is one of the biggest threats to DSA’s organizational health.

Political inertia: The status quo is an incredible hurdle to overcome. Defeating it requires tenacity and ingenuity and throwing many different strategies at the problem.

Prevailing attitudes: For example, politics of resentment. “Why should lazy people get health insurance?” “Why should Donald Trump’s kids get free healthcare?” Another attitude: it would cost too much. Each of these needs to be identified and convincingly overcome.

Black Swans: Political discourse of the day tend to center in constant reaction to the agendas of those in charge and/or centers around external phenomena (e.g. disasters like Maria).

Energy: Any support that could come from unions might be immediately sapped when an unfavorable Janus v. AFSCME decision comes down, forcing organizers to focus on internal organization. Beyond problems for coalitions, it’s difficult to sustain momentum over a period of years.

Capacity among chapters: Some chapters are big, but most are small and new. Some are run by people without a much background in politics (which is good! We want that! But we need to give y’all opportunities to learn skills). The uneveness makes one-size-fits-all approaches a waste of resources. Furthermore, every chapter is already working on something, even if it’s simply housekeeping.

Size: An active and motivated movement for socialism is still really small. It needs to grow. It’s great that we have enough members to force Deputy Director David Duhalde to dress up for the DSA meme stash’s amusement on Halloween, but we gotta keep growing. Top-line numbers like 31,000 members don’t tell the true story. A much, much smaller number is actively engaged. Often the most engaged end up bogged down in the boring business of running a chapter.

Communication: Our channels for communication are disparate and opaque. Decentralization can be great at penetrating new networks of people, but can also be burdensome to follow along. It’s stupid that an overwhelming listserv, lengthy Facebook posts, super-exclusive twitter DMs and Slack channels, Jacobin magazine and *cough* Medium *cough* have become our town halls. They’re inaccessible to most of our members who aren’t part of an insular scene of perpetually online people. The worst part is that while everyone acknowledges this, nobody can agree on a platform. That sucks.

Burnout and frustration: At minimum, given a purely electoral strategy to win Medicare for All, we’re looking at a five year timeline. Over that time, we will lose a lot of battles and face numerous frustrating setbacks. People will burn out and we’ll lose good organizers to simple frustration. Furthermore, without considerable wins to champion, growing DSA will become difficult.

This is some sour information, I agree, but if we’re not thinking about these sorts of things and have plans in place to counter them, they will blindside us. In some cases, they could fatally harm us.

Strengths and opportunities

And yet we have all been attracted to DSA itself because we see in it many strengths. As an organization, at both the local level and nationally, we have the opportunity to forge coalitions with other like-minded organizations across and array of issues. This feels like the best shot we’ve had in a hundred years.

Confederated chapters: Occupy Wall Street suffered a tyranny of structurelessness where DSA might not. Our model defines clear leadership at both the local and national levels yet maximizes autonomy through clever decentralization.

Multi-tendency: Because we’re not a monolith, it’s a lot more difficult to pin us down. That’s an advantage, not a necessarily a curse. Our model maintains flexibility among how democracies are organized within each chapter. This leads to varied organizational tactics (e.g. East Bay has a single campaign, New York casts a wide net). We can walk and chew bubble gum at the same time.

Plurality: I value dissent and I believe everyone else in DSA should value it as well. But if you don’t, that’s fine, too.

Big tent: Everyone has politics that are a mess. Everyone. We recognize that and work through those differences together, which sometimes creates friction (online) but most of the time creates stronger bonds (offline).

Organizers: The main attraction of DSA is the quality of organizers who have joined. As a member-run organization (as opposed to a mobilized membership), those people also have a say in our future. DSA has attracted smart organizers who can sharpen everyone around them.

The vulgar opportunism of certain Democrats: Even if the Democrats who now publicly support Sanders’ and Conyers’ bills try to backpedal, they’re currently contributing to an overall narrative that socialism is winnable. So much so, that the republicans are already red baiting.

Institutionalized Coordination: National Working Groups, regional organizations, state organizations and chapter leaders, along with a revamped chapter mentorship program, could form the basis of open and formal internal discussion.

Teenagers: If we don’t win, they will.

Develop a broad strategy

Mission, values and success

To develop a strategy we must do a few things: determine a mission and identify values and create a vision of what success looks like.

Amber A’Lee Frost put it best in defining a set of values that are divorced from any existing symbolic legislation. What are those values?

  1. A single program — not a patchwork.
  2. Comprehensive coverage — essential health benefits including inpatient and outpatient services, drugs, supplies and medical equipment, dental, optical, long-term care, and a full range of reproductive care.
  3. Free at the point of service — financed through taxes based on ability to pay, not shifting costs onto the sick: no fees, no copays, no deductibles, no cost-sharing from the patient side.
  4. Universal coverage for all U.S. residents — non-citizens included.
  5. Jobs — replacement and severance for those affected by the transition.

These are, very specifically, a baseline written by a handful of members and elected leaders which we think everyone will agree upon.

We can (and should) have open debate whether or not these are representative of our demands or that the process for determining these values must be more inclusive of stakeholders in the field or whatever, but the point is this is a start. We have to constantly review these demands and adapt them to changing conditions.

What does success look like? Is it the above values? I tend to think this is not a definition of success. It’s a start. Medicare for All that includes abortion care, that is free from the first dollar on, that is available to non-citizens is just the tip of a socialist vision of a healthcare system that prioritizes human needs above profits, is a step toward the goal of fully socialized healthcare and the elimination of medical debt.

Solidify our position

What resources, allies and real capacity do we have? Aside from the obvious ones like National Nurses United, Labor for Single Payer, Physicians for a National Health Program and Our Revolution/Bernie Sanders, how else can we foster a movement strategy? Many of these organizations have short- and mid-term electoral goals, but there are other organizations out there that work on “healthcare as a human right” issues—often directly with poor people at free clinics—so we ought to identify them and reach out.

We also need to address conditions on the ground for our chapters. We have all read and heard much handwaving on the issue of a national campaign vs. a local one. We ought to quash the idea that chapters in red states will somehow benefit from the work of blue state chapters and DSA can therefore bypass presumed hostile local conditions. Ceding ground in places like West Virginia and Wisconsin is foolish. This is exactly what liberals do and it’s what allows the Right to exploit deeply populist people via reactionary cultural resentment. But we have to go beyond relegating chapters in these places to merely fighting to preserve what little we have left. We have to become proactive in our social, economic and political maneuvers there. If we can’t find a viable way to bring the national healthcare discussion to White Sulphur Springs, Montana, we’ll never win socialism.

What is national but a superset of local chapters? There is no way to have national campaign without the support of locals. My own chapter overwhelmingly chose single payer over other issues as the biggest priority for national, but our local conditions make acting on a Medicare for All campaign awkward. It’s not as simple as living in a “red state,” whatever the hell that actually means.

We don’t have the opportunity or capacity to disrupt insurance power here. The bigger issue is that healthcare isn’t our top priority because ICE actively works with local police, because our elected officials refuse federal grant money for public health translators, because the state mill and elevator profits have been pilfered by the state legislature to pay off loans taken out by our state bank, in turn used to pay overtime to cops who terrorized DAPL protesters in the middle of nowhere.

Y’all, many of us have more immediate problems right now.

We can’t make someone who’s cousin is being held in an ICE detention center give a shit about a single payer campaign that’s a half a decade or more away from winning. That isn’t to say people disagree with Medicare for All. It’s a just matter of priorities. This is why socialist strategies and campaigns must have intentionally wholistic points of view. If we’re not thinking about how Medicare for All is also an issue of labor, of the environment, of internationalism (show me a list of the poorest counties in America and I will show you a list of sovereign nations within our borders), etc., we’re not thinking hard enough about all the possible points of entry to socialism for regular people who don’t happen to have a Catalyst subscription or the time to listen to Chapo’s Grey Wolf feed.

We have to have an honest discussion about how uneven our capacity is from chapter-to-chapter and how we need to not only have better chapter development programs, but structures in place to even out systemic disparities.

I tend to believe that local chapters know what is best for them; smaller democracies are better than big ones. Locals don’t need to be told what programs to work on, rather, they need resources in order to work on the programs they decide are the most important. Chapters need support programs and relevant political education materials that help them promote a comprehensive idea of socialism in their communities.

But power isn’t about defining the problem of capitalism. If it were, we’d have socialism by now. It also isn’t about presenting the best alternative narrative. Right now it’s about building numbers: a core base and broader support. Our programs must intentionally plug new members into capacity-building roles. They must face outwardly, reaching into existing infrastructure and networks (churches, campuses, unions, PTAs, fantasy football leagues, and so on). Many people will take action not because we can convince them Medicare for All in particular is the best mid-term goal for seizing power from corporate interests, but because something else catalyzes them: their job, their faith, their school, their community or their family. As organizers, we must be flexible in approaches and in tune with those interests. We must build relationships around those interests and work on a wholistic socialist program aimed at identifying power we can realistically capture and build upon.


In another part that I will release later this week, I’ll explore how I think we ought to internally and democratically establish approaches to address our weaknesses and threats and how we can collectively discover and leverage strengths and opportunities in support of a broad movement. I’ll also lay out, clearly, what I think any national program for Medicare for All ought to look like. In particular, I think we need a far more open and transparent coordination between members of the NPC, our potential allies and national working groups that includes open lines of communication and advice with chapter leadership and those on the ground doing the work. This whole thing needs to be opened up for discussion to allow different tactics, orientations and points view to emerge. A winning strategy will require a battery of tactics.