A quick recap: In the first blog in this series, I laid out what we at Community Catalyst see as the key goals of health reform—quality affordable coverage and care for all, lower costs, better health status and consumer engagement and protection. I also put these health policy goals in a larger context—that every social welfare policy debate is also a proxy fight about the role of government in our society and the efficacy of collective action.

In the second part, I outlined the key challenges to achieving these goals, including fear of change and corporate America’s powerful and abiding opposition to progressive taxes and the expansion of the welfare state. I highlighted the key “swing” role that the big economic stakeholders in health care could play in the debate, and underscored the important role that not just party control but also size of party margin in the House, and especially in the Senate, have played in shaping the outcome of previous health policy debates.

In this final installment, I will focus on six key elements of a strategy to overcome the obstacles and achieve our health reform goals.

First: “Play the ball where it lies” (and it lies in the states)

The flip in party control of the House in 2018 brought at least a temporary halt to congressional efforts to repeal the ACA and slash funding for Medicaid. For the most part, for better and for worse, there will be little action from Congress on health policy at least through 2020 and possibly longer if control of the federal government remains divided after the next election. That means the most important venue for reform lies in the states. And indeed, we see states all across the country working to bring forward the next generation of progressive health care ideas. To be sure, a more sympathetic administration could greatly aid these state efforts. But the essential point is that until there is a “Democratic trifecta” in power at the federal level, states will be the key arena for health care reform.

Even if Democrats do retain House and take control of the White House and Senate, the margin in both chambers will matter. As discussed in part 2, narrow political margins are unlikely to produce sweeping change. What they can produce, however, is incremental reforms that will further enable states to advance the goals of better health care and better health.

Second: Create a common interim agenda

The divisions between those who seek a rapid shift to a single national public insurer and those who advocate a more incremental approach possibly ending in a multi-payer system may seem substantial. But in reality, they are minor compared to the differences between those who embrace the goals laid out in part 1 and those who do not.

To help move their common agenda forward we need an interim common agenda—one that could be pursued in a closely divided political environment—that is compatible with either a single payer or multi-payer future. Expanding public coverage and public financing and using public purchasing power to lower prices (e.g. for prescription drugs) should be ideas that all proponents of universal coverage can agree to. Building out a menu of these types of changes can allow people with different positions in the single-payer versus multi-payer debate to work together productively to make improvements in the health care system and also further the key overarching “meta goals” of showing how collective action can lead to policy change and better lives.

We should also ensure that a common interim agenda is not limited to coverage and cost containment—as important as those issues are. We should also ensure we are advancing an agenda that promotes better quality and improved underlying health status with particular focus on promoting racial justice and improving care and health for other groups that face discrimination.

Third: Splitting instead of lumping

The greatest virtue of single payer is, in some respects, also its greatest weakness. Single payer puts coverage, lower administrative costs and lower provider prices into one package. While this has a lot of policy appeal, it is not necessarily an ideal political mix.

Splitting these issues from each other reduces the opposition to any one proposal and allows for the creation of stronger coalitions including both consumers and other stakeholders. Take coverage for example. Any coverage expansion will require new taxes and result in a progressive transfer of wealth. It will also expand the role of government and expand the benefits people receive independent of work. As a result, it will encounter strong political resistance. If establishing government guaranteed coverage is paired with an existential threat to insurers plus big provider payment rate cuts, the political resistance will be much stronger. But if coverage expansion stands on its own or is paired with other reforms such as those focused on reducing racial health disparities, health care stakeholders will either be supportive or at worst neutral.

What about cost containment? It’s not a single issue—again we should think about the benefit of splitting instead of lumping. Consider for example that insurers may be an ally in reducing drug prices, while providers are likely allies in reducing administrative costs.

Fourth: Think of reform as an iterative process

No current bill, even the most far reaching, encompasses all of the goals described in part 1. Especially if political margins are narrow, the reach of federal reform will be necessarily be limited. Rather than think of reform as a one-shot deal, it is more useful to think of it as occurring over time with the primary focus of action shifting back and forth between the state and federal level.

Fifth: We can be in left field, but we have to be in the ballpark

It is axiomatic that you want to go into a negotiation seeking more than what is minimally acceptable. But it does not follow from that the more you demand, the more you win. While “moving the Overton window” is a phrase much in vogue these days, many critics consider the idea to be the political science equivalent of the “Laffer Curve”.

Finally: Put first things first

A lot of urgent business will confront a new united Democratic government should we have one. Issues such as climate change, immigration reform and income inequality should not wait. From a health reform perspective, the most urgent and important of the issues in the queue may be democracy reform. In order to create a health care system that better meets the needs of people, we need a political system that better encourages participation and better reflects the will of the people. Safeguarding voting rights and curbing the outsized influence of big money in politics are key changes that will make future health reform much more possible.

Conclusion

Community Catalyst has five overarching goals for health reform. We believe it is important to be clear about those goals. But clarity about goals does not require us to attempt to achieve them all simultaneously without regard to the political environment around us.

While our goals remain unchanged, we need to adapt our immediate agenda to our circumstances in order to make progress. The history of previous health reform efforts—both successes and failures— suggests that big change is possible in certain circumstances and also that it is possible to overreach with significant negative consequences. If we are strategic, patient and persistent, we can take advantage of any opportunity to create a health care system that works for everyone.