This Q&A is part of Sarah Jaffe’s series Interviews for Resistance, in which she speaks with organizers, troublemakers and thinkers who are doing the hard work of fighting back against America’s corporate and political powers.
After the House of Representatives approved legislation to repeal and replace significant parts of the Affordable Care Act last week, Sarah Jaffe spoke with Adam Gaffney, a physician in pulmonary and critical care, as well as an instructor at Harvard Medical School. Gaffney, who is a member of Physicians for a National Health Program, which supports single-payer national health insurance, talked to Jaffe about the latest Trumpcare plan and what needs to happen next. It has been lightly edited for length and clarity.
Sarah Jaffe: Adam, what are the Republicans trying to do to us?
Adam Gaffney: Well, if you look at this plan, I don’t really consider it much of a health care plan as a conduit of dollars from working class people to rich people. It keeps [some] of the Affordable Care Act in place, but it denigrates it, it twists it and it corrupts it to the benefit of the very wealthy.
Just from the big-picture perspective, what are some of the things it is doing? Well, on the one hand, it is cutting programs, including a major cut to Medicaid. Over 10 years, we are talking about over $800 billion in Medicaid cuts; that is about a quarter of federal spending. That is going to throw millions of people off of Medicaid. As you know, Medicaid is a program for lower-income people that covers more than 70 million people.
The second thing it’s going to do is weaken the subsidies that people use to buy health plans on the marketplaces, the so-called “Obamacare” plans. Those are still going to be around — the private insurance industry will still be subsidized — but those subsidies are going to be worse, they are going to be more regressive [meaning they take a proportionally greater amount from those on lower incomes] and they are going to be less adequate for many folks. That is one side of the ledger.
On the other side of the ledger there’s just a huge redistribution of wealth upward. Essentially, it eliminates a variety of taxes that the Affordable Care Act put in place, and that is almost entirely going to benefit the very wealthy. Here’s some numbers from the Congressional Budget Office’s latest estimates. We are talking about $127 billion that people making over $200,000 for lower Medicare tax cuts; $145 billion over 10 years to the health insurance industry; and $172 billion over 10 years for lowered capital gains taxes or high-income earners. And that isn’t even everything. Big picture, we are weakening the health care safety net, we are taking those dollars and we are funneling them upward.
SJ: Because, of course, cutting capital gains taxes is very related to health insurance. Right?
AG: They would argue that this is part of the Affordable Care Act and that they are simply repealing it, but functionally speaking, this is an upward redistribution of wealth.
SJ: This is the second time, the Republicans finally managed to butter and squirt this thing through with one vote to spare. What happens next here?
AG: It goes to the Senate, where it faces serious headwinds. A lot of senators are very wary about its effects, particularly on Medicaid. There is much less room for error in the Senate. They can’t lose more than a couple of senators and still pass it through. My gut feeling — and I am not very good at political prognostication — is that they are going to pass something, but it is going to be a much more watered-down version of the House bill. Then the question will be: Is the House willing to pass that? I don’t know.
The version 1.0 of Trumpcare was sunk mainly because of the resistance from the hard right within the House, the House Freedom Caucus. They did not feel like the wall went far enough. And that was a pretty ugly law. The question is: How much can the Senate change this bill and still have it be passable in the House? That remains to be seen.
SJ: There is a definite sense right now that a lot of the so-called “moderates” who wound up voting for this, did so with the expectation that the Senate would change it anyway.
AG: That is certainly the case. I think the expectation and the hope is that they would change it. I think there is a realization on the part of many moderates in the House — so-called “moderates” — that this is an ugly, unpopular bill. The last poll I saw was the one that was being cited around the time of version 1.0 that showed 17 percent support for Trumpcare. That is a dismal level of support.
— Adam Gaffney
Part of that is because of what Trump actually campaigned on. His health care promises were vague, but they aren’t what he is doing now. He said he wasn’t going to cut Medicaid. He said he wasn’t going to cut Medicare. He basically promised more health care for everybody. So, every time people sort of chuckle and say, “Oh, I can’t wait to see the Trump voters get what they voted for,” on the one hand, I think that is really nasty and is not how we should be approaching politics.
On the other hand — and you can fault them for being poorly informed — but Trump did promise something different. He promised more health care, not less. This is just less health care. It is really a quantitative switch on health care spending. It is less money going into the health care safety net and more money going into the pockets of high-income people and health care companies.
SJ: Talk a little bit about the process by which the Affordable Care Act itself came to be. That was after a summer of yelling at town hall meetings from the tea party trying to stop Obamacare. Can you could talk a little bit about that process and where the weak spots in that process were?
AG: I think if you want to look at the weak spots in that process, you have to go back to the beginning, which was a rejection from Day One of single-payer, of something more expansive. In the 2008 Democratic primaries, there was already an assumption that single-payer was not going to be an option and basically all of the candidates were opposed to it. The candidates and [Sen.] Max Baucus (D-MT) certainly conceived of a very much middle-of-the-road compromise bill from Day One.
I think the biggest flaw in the Obamacare process was actually before the summer of discontent and before the tea party were involved and really starting from the assumption that we had to do something much more narrow.
People talk about this sort of origins of the Affordable Care Act. Some people say it is a Heritage [Foundation] plan, which is true only in so far as it incorporated the individual mandate, but it is true that the Affordable Care Act was largely modeled on an even older plan. It was sort of modeled on Nixon’s plan for the 1970s. Ted Kennedy in 1970 put something out there called the Health Security Act, which is basically a single-payer plan. Nixon put up a counterproposal that included employer mandates and an expansion of a Medicaid-like program. So, in many ways, the fatal flaw of Obamacare was its assumption from the beginning that we had to involve the private insurance industry as a key element within our health care system.
SJ: I think it is also worth talking a little bit about the way that the politics around so-called “Obamacare” have played out. You find that people either don’t know that what they have is the Affordable Care Act or people were frustrated because of the jump from being eligible for the Medicaid expansion to then suddenly having to pay out of pocket even for subsidized care. Can you talk about the way that the construction of this bill made it easier to attack?
AG: Well, the construction of the bill was that it reinforced an existing fragmented system. It did not create a new public benefit. So as soon as you do that, you are sacrificing popular support. If you look at a program like Medicare, which is a universal benefit that you get when you turn 65, obviously, it is extraordinarily popular. People know what they are getting.
Under Obamacare, it is very unclear. Most people are unsure of how they are affected by the law. It doesn’t create social solidarity in the same way that the universal public program does.
I think the Medicaid expansion was good and it helped a large number of people, but as you say, many people in the middle ground are still being squeezed. Deductibles have been rising dramatically in recent years. It is not the fault of Obamacare. It preceded Obamacare. But, Obamacare has been blamed for it.
Copayments, deductibles, coinsurance are rising. People are finding that although they are insured, they are unable to afford going to the physician or getting a prescription filled. That is a major problem. I think that is feeding into a lot of discontent around this law. I think Obamacare has not created the social support necessary for its own propagation as a result of those inherent weaknesses.
SJ: That said, one of the interesting things that it did do was reinforce the idea that the government should do something about your health care problems. Then, we do see people, again, reacting to the Republican plan to take away what health care people do have with this intense anger.
AG: There has been a whole shift in the way we think about health care toward, at least, an implicit recognition of health care as a right. Conservative columnist Charles Krauthammer sort of said this on Fox the other day. As he said, and I agree, even conservatives are having to defend their health care plan with this implicit argument that everybody deserves coverage. In a way, that suggests that the battle in the discursive realm is actually already being won. People increasingly believe that health care should be a right.
The fact that the Congressional Budget Office released its estimates of Trumpcare and said that 24 million people would be uninsured was shocking. That was terrible for the bill’s popularity. Nobody could defend that. In a real free market sense, that should be fine. If 24 million people “elect” to not buy insurance, who are we to say that that is a problem?
Nobody really thinks that way outside of a very narrow spectrum of zany and cold-hearted libertarians.
I think there has been an implicit, progressive acceptance of the notion that the government should ensure that everybody has access to health care. That is one good thing that has certainly been happening.
SJ: On that note, how do people stop this thing from proceeding through the Senate?
AG: We have to stop it. Even those of us that believe that we need to go well beyond the Affordable Care Act should absolutely recognize the harm that this would do, the deaths that it would cause. A lot of people have put out estimates of potential deaths that could result in something like this. As I wrote in my recent article in The Guardian, around 24,000 people a year will die each year if 24 million people lose their health insurance.
— Adam Gaffney
Lives are on the line and suffering will increase. We have to stop it. It is an all-hands-on-deck approach. I think every US senator has to be picketed and targeted. I think that they should know that if they vote for this they are going to face the full wrath of the citizenry. I think the more protests, the more activism around this in the very short-term, the better.
It is obviously going to play out one way or the other very soon. The Trumpcare battle is a short-term fight in that if they don’t get this through soon, and they need to to use reconciliation to get it passed, it is dead.
SJ: Explain reconciliation for people who don’t understand how that process works.
AG: In general, a filibuster in the Senate means you need to have 60 votes to overcome it. There’s going to be no Democrats who will go along with the health care bill, the Trumpcare bill, as far as we know. In order to get around the 60-vote requirement, there is a provision of reconciliation that allows bills that have a predominantly budgetary impact to be passed with a simple majority. There is a timeline for that. It has to be done relatively soon.
There is actually some question whether some provisions in the House bill would even be allowed to be passed through reconciliation. There is something called the Byrd Rule that describes what sorts of things are allowed to be included. We don’t even know if the House bill in its current form could actually pass as reconciliation. But regardless, if they want to pass anything, it is going to have to be through reconciliation because unless they really come to the center in some way, they are not going to get enough Democratic senators (or any) to get to the 60 votes.
SJ: You have been part of the fight for single-payer for quite a long time now. Talk about where you think that fight is and why it is important to keep it up even as we are trying to stop the health care apocalypse here.
— Adam Gaffney
AG: It is critical because the status quo is very unjust. Think of it this way: Trumpcare is going to increase the number of uninsured by 24 million and in 2016, according to the National Health Interview Survey, there are already 28 million people uninsured. Then, there are even more people than that who are underinsured who are, again, having high copayments, high deductibles, unable to go to the doctor, unable to fill prescriptions.
The status quo is bad and people are suffering. As long as that is the case, we are going to keep the door open to right-wing attacks. There will always be a right-wing economic populist like Trump who is going to say they will make health care better. Well, we are opening the door to that if we don’t do something about it.
It is critical that we keep the fight going for a better tomorrow, for a better future of health care, and not just rear-guard defensive battles of keeping things the way they are. The reality is that people are not happy with the way things are today. It is not good enough. The counter argument might be: Well, what is the likelihood? Are we ever going to get single-payer passed under this current government? No, we are not. But we could under the next government. This is the time when we coalesce. This is the time when we put together our arguments, we put together our coalitions, when we begin to turn on senators and representatives to single-payer so that when the political tide turns, we are prepared. We need the grass roots armies in place now to do that.
SJ: How can people be part of those grass roots armies? Where can they get involved with health care organizing?
AG: There are so many different organizations out there that are focusing on single-payer health insurance. My organization is Physicians for a National Health Program. It is centered around medical professionals, although we certainly have other members as well. There is Healthcare Now and various labor organizations who are very involved in this. National Nurses United, which is the largest nurses union in the country is very much behind single-payer.
I think it depends on where you are and what sort of work you want to do, if you want to get involved in a group that is maybe affiliated with your profession or not. There are a host of groups out there under something called the Campaign for Guaranteed Healthcare, which is a coalition of different groups. You can go to that website and see some of those groups. There is lots of activism on this issue.
From a larger perspective, health care activism can really be a critical pillar of the left moving forward. I think it is an issue that does bring people together and resonates with the general population. A Gallup poll from last year finds 58 percent support among the general public for single-payer health care. This is a good cause that could help galvanize energy on the left.
SJ: How can people keep up with you and your work?
AG: Well, like some other people, I am on Twitter: @awgaffney, and I have a website: theprogressivephysician.net. I would also send people to my organization’s website, which is pnhp.org. It has some great resources on single-payer health care and on the policy issues behind it so that we can really mount our most effective arguments.
Interviews for Resistance is a project of Sarah Jaffe, with assistance from Laura Feuillebois and support from the Nation Institute. It is also available as a podcast on iTunes. Not to be reprinted without permission.