In the wake of President Donald Trump’s victory last November, Democrats like Kyle Horton thought there was no hope for saving the Affordable Care Act. “I would have said it was lunacy right after the election,” the North Carolina physician told me on Friday, “and now look where we are.” The defeat of the Senate’s repeal bill early that morning, she enthused, “shows that our resistance and our engaging people on a grassroots level to tell their personal stories is really working.”

But now, with outright repeal off the table indefinitely, Democrats face a new set of challenges in talking about health care. Should they focus their messaging on Trump’s plan to sabotage the ACA administratively, or on working with Republicans to solve the real problems facing Obamacare? And is now the right or wrong time to sell Americans on moving to a single-payer system (a.k.a. “Medicare for all”)?

These are particularly pressing questions for someone like Horton, who’s running for Congress next year in her state’s Seventh Congressional District. She acknowledged the risk that, after last week’s victory, Democrats could let their guard down against enduring threats to Obamacare.

“There may be more complacency,” Horton said. “In particular, I am thinking about the big pharma and insurance lobbyists and how much power they have right now in Washington. They could easily gut certain aspects [of the Affordable Care Act] as they’re pushing to ensure they’re not paying their fair share or to protect their corporate tax inversion schemes.” That’s why Horton says her party needs to “redouble our efforts to ensure that we’re educating people.... Probably not change our message, but ensure that the message never goes away between now and 2018, even if [Republicans] move on to tax reform and other issues.”

Democrats of various stripes are already working toward that end. The group Save My Care launched a national “Drive For Our Lives” bus tour on Saturday to rally support for the ACA. Indivisible Iowa flew a banner around Cedar Rapids warning Republican Representative Rod Blum, “WE ARE #HEALTHCAREVOTERS!” And Sabrina Singh, deputy communications director at the Democratic National Committee, assured me “the issue of health care isn’t going away despite the fail of the repeal vote.” “We’re still going to talk about health care,” she said, noting that Republicans “could certainly try again this year or early next year, so it’s going to be hard for voters to get complacent about the issue.”

Winnie Stachelberg, vice president at the Center for American Progress, was more adamant. “I think health care is going to be one of the major issues punctuating outside the Beltway and a big issue in races in 2018,” she said. “In the starkest terms, Trump and Republicans tried to take health care away from millions of Americans, and Democrats prevented that from happening.”

But if the party is united in its belief that health care is a winning issue for them, it’s divided over how to capitalize on it. As The Washington Post’s Dave Weigel put it on Sunday, “Democrats have not yet formed a consensus on how to approach health care again.” While the establishment is focused on bipartisan fixes to the existing law, progressives are pushing for the party to embrace single-payer—to, in the words of Progressive Change Campaign Committee co-founder Adam Green, “take one of the most popular brands in American politics and run it down the court to victory.”

“We are going to wrap ourselves in the flag of Medicare,” he told me on Monday. “The public option will become ‘the Medicare option’ and single-payer will increasingly be called ‘Medicare for all’.... We’re going to dare Republicans to oppose expanding Medicare to millions of Americans.”

Centrists like Jim Kessler, co-founder of the think tank Third Way, think such an approach would be politically disastrous. He said the party should “stay away” from single-payer in 2018, and focus instead “on jobs and the economy.” He added, “We just saw the danger of riling up your base with a promise you can’t keep.”


In Washington, D.C., late last week, hundreds of Democratic candidates for 2018 turned out for training with the Progressive Change Campaign Committee, and many of them felt newly energized to campaign for single-payer. “I’m going to start talking about the best improvement to Obamacare: Medicare for all,” said Antoinette Sedillo Lopez, who’s running in New Mexico’s First Congressional District.

Pam Keith, from Florida’s Eighteenth Congressional District, is even crafting an appeal to conservative voters. “Progressives believe in single-payer health care,” she told me. “They want to get there for the benefit it gives to individuals, but I want to get there for the benefit it gives to employers. If you make pizza, you’re not in the benefits business. If you cut hair, you’re not in the benefits business. Now, you as an employer have the burden—the lack of freedom, the obligation—to spend resources finding plans and paying for plans, and all of this takes away from your core mission of making pizza, cutting hair, or providing electricity. With single-payer, all these businesses and employers are now absolved of that responsibility. Ain’t that a great thing for employers?”

Democratic leadership is taking a different approach. Senate Minority Leader Chuck Schumer has said single-payer is “on the table,” but at a press conference on Friday he urged bipartisan fixes to the existing law. “I think at the very beginning we should stabilize the system. We should make permanent a cost sharing, which keeps people’s premiums down and keeps the counties that are covered up,” Schumer said. “We should look at reinsurance.”

“Now is the time to work together to strengthen the Affordable Care Act,” Stachelberg, of CAP, told me. She said that means greater certainty for insurers by guaranteeing the continued payment of government subsidies, reimbursing insurers for covering high-cost patients, and assisting those areas of the country that currently have one or no insurers—filling insurance gaps for underserved counties.

Green told me passing “technocratic fixes” to the ACA is “certainly not a 2018 message” for Democrats. Progressive groups like MoveOn and Our Revolution think candidates should be pushing “Medicare for all” across America. But Tyler Law, the Democratic Congressional Campaign Committee’s press secretary, isn’t pushing for a uniform approach to health care in every district. “I’m definitely not going to prescribe any one-size-fits-all approach,” he told me.

Kessler argues that protecting Obamacare and shoring it up is a full-time job,” even if it isn’t the sexiest political issue. There aren’t going to be a million people rallying holding signs that say ‘market stabilization on the exchanges,’” he said, later adding, “I don’t think the country is clamoring for another major debate on another health care overhaul.” Even if some Democrats do support moving left on the issue, he argued, there’s reason for them to focus on fixing the ACA first: “If people don’t think Obamacare is working, I don’t see an expansion to single-payer health care on the horizon. I think the public will go in the other direction.”

Even some progressives agree. Horton is holding out for bipartisan fixes to the country’s health care challenges, and she spoke candidly about why she’s not on the “Medicare for all” bandwagon.

“People feel alienated if they feel like you’re relying on politics as usual and if they feel like you’re being extreme and not listening to them,” she told me. “We know on our side of the aisle that Obamacare involved hearings. There was a lot of public input collected. It wasn’t rammed through Congress. But in my district a lot of the voters have bought into the repeated dialogue that it was rammed through, that the Republicans did the same thing the Democrats did to healthcare.”