The struggle for healthcare at the state and national levels: Vermont as a catalyst for national change

For more than two years, the Vermont Workers’ Center, a community-based workers’ rights organization, has been leading a statewide campaign to implement a universal and equitable healthcare system in the state of Vermont, the Healthcare Is a Human Right Campaign. This campaign won legislation in the 2010 legislative session which commits the state to implementing a new healthcare system which meets the human rights principles of universality, equity, accountability, transparency and participation. Dr. William Hsiao, who designed Taiwan’s single-payer system, is designing three options for the state, one of which will be a single-payer system and all of which must meet the human rights principles. While there are many struggles ahead to make sure that the state chooses and implements a new plan that actually meets human rights principles, Vermont is certainly headed in the right direction.

The contrast with the national situation is stark, especially in light of last week’s election results. The 2008 election of Barack Obama as President and majorities for the Democratic Party in both houses of Congress opened up the possibility for national healthcare reform for the first time since Bill Clinton’s disastrous attempts in the early 90s. However, Obama followed much the same script as Clinton, refusing to stand up to the insurance companies, putting forward proposals that would protect the insurance companies’ profits, and yet still being ruthlessly attacked by these same companies and their allies in both parties. While Obama did finally succeed in passing a bill, it is based on retaining and consolidating a market-based system and will not solve our healthcare crisis. Obama’s and the Democrats’ poor performance in the political battle over healthcare contributed mightily to resurrecting the Republican Party, which regained control of the House of Representatives in part on a promise to repeal or de-fund the legislation. In contrast, Vermont elected a new, Democratic governor who campaigned on a platform of support for single payer — a political stance made possible and popular in large part because of the Healthcare Is a Human Right campaign.

In this situation, how do we best struggle for the right to healthcare, and the right to health more generally? At the US Social Forum in Detroit in June, Vermont Workers’ Center members got a chance to participate in several workshops, exchanges and People’s Movement Assemblies around these questions, and it has prompted us to think more about how our efforts within Vermont can best contribute to building a national movement.

In Vermont, there are several strong networks of single-payer and healthcare reform advocates, as well as a high-profile and popular politician — former U.S. Congressman and current U.S. Senator Bernie Sanders — who regularly talks about the importance of single-payer. Their work over the past decade or more laid important ground-work for this current victory. However, what the Vermont Workers’ Center has brought to the struggle, and what we believe has contributed to moving the struggle forward dramatically in the past two years, is an organizing practice based on the understanding that the struggle for universal healthcare cannot be separate from building a social movement — i.e., it must engage the people most affected by the problem on a mass level, and be animated by a vision of a better, more equal society.

This practice can be viewed through two of our slogans — the title of the campaign itself, “Healthcare Is a Human Right,” and our frequent reference to “changing what is politically possible.” The first reflects our practice of engaging in ideological struggle — waging the “battle of ideas” (or, more accurately, “values”), and the second reflects our explicitness about power, and changing power relationships by doing mass organizing among the people affected by our healthcare system. We believe that both of these are key components of a successful healthcare struggle.

Ideological Struggle: Using the Human Rights Framework

When we began organizing in 2008, we opened each organizing conversation with a new person with the question: “Do you believe healthcare is a human right?” Over 95% of the thousands of Vermonters we have spoken with agreed, and this is the basic point of unity on which our campaign is built. With the assistance of the National Economic and Social Rights Initiative (NESRI), we have further developed this basic claim into five human rights principles for healthcare: universality, equity, accountability, transparency and participation.

Using the human rights framework allows us to start by connecting with people around a basic shared value, one which is deeply intertwined with what they hold most dear: their children, parents, spouses and partners, and their own bodies. It connects the very personal to a broader set of values — values such as caring, community, and social solidarity — that are often in contradiction with existing institutions and social relationships. The human rights framework allows people to develop a political understanding of their personal experiences with the healthcare system. This political understanding then allows them to make judgements, and take action, based on a vision of a better society rather than the artificial constraints of what politicians and pundits consider “politically possible.”

The human rights framework also encourages movement-building discussions of how healthcare intersects with other issues such as domestic violence, racism, immigration, war, privatization and attacks on the public sector. Building a shared commitment to human rights around healthcare gives us a chance to move people on other issues when the hegemonic ideologies they have absorbed from the dominant culture (racism, sexism, individualism and consumerism, etc.) come into conflict with the human rights framework.

Building Power: Mass Organizing Campaigns

The Healthcare Is a Human Right campaign has used a wide variety of tactics, beginning with those drawn from human rights strategies such as documenting people’s experiences of human rights violations and holding human rights hearings, and, as the campaign got to the point of moving legislation, including traditional lobbying and accountability sessions with legislators.

These activities have always been backed by our ability to engage and mobilize hundreds and eventually thousands of people. Our mass organizing campaigns — collecting surveys, postcards, and petition signatures — have directly engaged over seven thousand Vermonters (more than 1% of the state’s population), and indirectly engaged a far wider part of the population through a variety of successful, grassroots-driven media strategies.

A mass organizing campaign is more than just using a “mass” tactic such as a petition or survey. Especially in the internet age, it is easy to collect a large number of signatures without really having one-on-one organizing conversations — the kind of conversations that build relationships, engage people in a discussion about values, and move them to become more active and engaged. Our mass campaigns are always built around the premise that the survey, postcard or petition is a tool that allows us to have those conversations, to engage each person who takes the survey or signs the petition in the “ideological struggle” for healthcare as a human right.

Mass organizing campaigns are useful not only for building numbers, they are also important tools for building leadership. The strength of our regional organizing committees around the state is that they are composed of people who have emerged from and carry out mass organizing campaigns — they are regularly talking to other people in their communities and workplaces, and moving those people to action.

Engaging in mass organizing campaigns means that we are, on a fairly regular basis, asking thousands of people to make a decision, based on their values, to participate in a political struggle. We are expanding people’s experience of “politics” beyond elections, online petitions and polite lobbying of legislators — the “low-intensity” democracy that is taught in high school civics classes. To overcome this traditional understanding, we are having lots of patient conversations with new members about not only the healthcare system, but also the nature of power, how social change really happens, and what it means to build a social movement.

The Role of Single-Payer Reforms in the Broader Struggle for Social Justice

The goal of our campaign is to enact a single-payer system in the state of Vermont, and we are not shy about stating that. However, we rarely emphasize it in organizing conversations, because our vision is much broader — social and economic justice for all. A single payer system is a reform that is necessary, but not sufficient, for realizing that vision.

We also understand healthcare reform to be a strategic opportunity in the struggle for social and economic justice, an opportunity to win a significant reform that can further the broader struggle. The healthcare system has become so dysfunctional that some sectors of the elite will accept the relatively radical reform of socializing the financing of healthcare in ways that it is hard to imagine happening with, say, housing. This division among elites, combined with the fact that single-payer will actually save money, makes it far more winnable in the current political context than any other struggle to establish human needs as public goods rather than commodities.

We are, however, clear that it matters how we win this struggle. Unlike some other single-payer advocates in Vermont, we are not promoting single-payer as “the most fiscally conservative solution” to the healthcare crisis. This is precisely the kind of slogan that, while seemingly pragmatic, actually reinforces the overall ideology of our opponents (small government, low taxes, etc.), and thereby undermines other struggles, such as struggles against cutbacks in the public sector and the looming struggle to prevent Social Security and Medicare from being gutted and/or privatized in the name of “fiscal responsibility.”

Single-payer in One State and the National Struggle

Proponents of struggling for single-payer on the state level, including us, frequently point to the Canadian example, where Medicare (the Canadian single-payer system) was first enacted in the province of Saskatchewan and later spread nationwide. However, what is frequently forgotten (or not known) about that history is that, immediately following the passage of single-payer in Saskatchewan, the province’s doctors refused to treat patients under the new system. The “Saskatchewan Doctor’s Strike” (though in reality more of a lockout of patients) lasted for 23 days; the healthcare reform was only saved because progressive physicians from across Canada, as well as from the U.S. and Great Britain, came to the province to help break the “strike.”

Changes in the healthcare system in the past half-century have vastly reduced doctors’ opposition to single-payer; however, new, more formidable opponents have appeared — a highly consolidated for-profit insurance industry and the vast pharmaceutical industry. Therefore, we believe that we cannot succeed in one state without the support of a national movement, one that is strong enough to take a victory in Vermont and spread it throughout the country.

In the 2011 legislative session, the Vermont state legislature will have the opportunity to enact a fully-designed single-payer healthcare system. Getting them to do it, however, will be a massive and intense struggle. We fully expect that there will be national insurance and pharmaceutical industry resources deployed against the effort, especially now that the federal healthcare debate is over. The insurance companies and other corporate interests are not going to see this as a local struggle, and leave their Vermont counterparts to fend for themselves. Therefore, we desperately need the national movement for healthcare for all to also view this struggle in Vermont as a national struggle.

Specifically, for our struggle to succeed, we need:

  1. Taking the offensive in other states. If the national insurance companies can concentrate all of their resources on Vermont, we face a much more unequal battle than if they are also dealing with serious offensives in other states. It is crucial that we not let the defeat on the federal level immobilize us, especially in those states that have a real chance to move single-payer legislation. Vermont is committed to providing whatever assistance we can to efforts in other states.
  2. Given that state governments will be mandated to create “exchanges” by the new federal legislation, there is also both an opportunity and a need to press state governments to make a realistic assessment of their state’s healthcare needs. In places where the movement is not yet strong enough to make a serious attempt to pass single payer legislation, study bills similar to the one passed in Vermont in 2010 could be an achievable goal.
  3. A national strategy of ideological struggle and mass organizing. While we recognize that passing state-level legislation is not immediately possible in every state, we believe that a unified effort across the country to engage in ideological struggle, combined with a unified mass campaign, would go a long way to aid state-level efforts, provide a context for the important work of critically evaluating the actual effects of the federal legislation, and rebuild our capacity as a national movement in the wake of the division and confusion that have resulted from the struggle over the federal healthcare bill.
  4. Resources. Finally, we of course need money to be able to pay our organizers. Much of the campaign is volunteer-driven, and we have run this campaign so far on a shoe-string budget, but as more and more Vermonters get excited and get involved, we need to have staff to be able to support these volunteer organizing committees.

Ideological Struggle: We need, as a national movement, to have an ideological framework, a set of concisely stated shared values. No matter how much we agitate for “single-payer” or “Medicare for All” or “HR 676,” our opponent’s values-based appeals to “liberty” and “freedom” are going to be more compelling for far too many people. The Right has spent the last half-century carefully constructing a narrative about government encroaching upon people’s freedoms — a narrative that appeals to many people’s values of individual liberty and their experiences of frustration with government bureaucracy. We must construct a counter-narrative which speaks to people’s values of caring and community, as well as their experiences with the healthcare system, and corporate power more generally. We believe that the human rights framework offers the best and most strategic option for countering the Right’s current ideological offensive, as well as their longer-term ideological dominance.

Mass Organizing Campaign: Our movement also needs to be getting out and talking to more people. It is not enough to be right, to have a good narrative and ideological framework, or even to have polling data that show that the majority of people support our position. We need to be engaging more people in one-on-one organizing conversations — that is the only way we will build to the scale necessary. Doing something together, as a national movement, would be a way for smaller local groups or chapters of national networks to do work within their current capacity, but still contributing to a real “mass” organizing campaign.

We believe that the national movement for healthcare needs to have a frank discussion about these issues, one that can lead to unity around a strategic plan of action incorporating both of these elements. An option that we have been exploring with our partner organization NESRI would be to submit a large number of individual complaints about the U.S. healthcare system, developed from a mass survey campaign, to the UN Special Rapporteur on the Right to Health. An effort like this, locally organized but nationally coordinated, could offer an opportunity to engage in ideological struggle, to amplify the voices of those most affected by the healthcare crisis, and to build relationships with the leaders of various communities and constituencies that are currently under-represented in our movement. This strategy has the advantage of being scalable (i.e., smaller local organizations could simply collect some surveys, while larger ones could organize human rights hearings, etc.), and it could also be combined with the work of assessing the actual effects of the new federal legislation.

We submit these requests for support and proposals for action to the national movement, knowing full well that we lack the resources necessary to coordinate any national action, as we are a small organization and will shortly be engaged in such sharp struggle on the ground in Vermont. Nonetheless, we want to share our thoughts and experiences with the national movement, because we fully believe that when we win in Vermont, it can serve as a catalyst for pushing forward the national movement, not only for single-payer, but for health and justice for all people.