When Micah Johnson was working for Abdul El-Sayed in his 2018 run for governor of Michigan, he was in the middle of medical school in Massachusetts, a state that by American standards has some of the best levels of health insurance and access to care. But his training exposed him to many of the shortcomings still endemic to even the most successful health regimes in the country, motivating his work for the insurgent progressive candidate promising voters a state-level Medicare for All program.

“I would come back and talk to my friends in medicine about what we were working on, and they would ask me, ‘is there some book or something about this that I could read to try to learn about it?’ And there wasn’t,” Johnson told Blue Tent recently in a joint interview with El-Sayed.

After El-Sayed lost in the primary to Gretchen Whitmer, he and Johnson got to work on filling that void. El-Sayed now hosts a podcast, America Dissected, for the liberal Crooked Media network, in addition to writing a regular newsletter and doing other media and academic work surrounding public health, while Johnson is completing his residency in Boston. Last month, the duo published a new book together, “Medicare for All: A Citizen’s Guide,” in an attempt to both debunk widespread critiques of single-payer, as well as to create a guide for the future of the Medicare for All movement.

“An absurd and tragic reality”

The push behind Medicare for All is at both a high watermark and something of a standstill, at least among its many disappointed supporters, who see a Democratic party still resistant to the policy. For El-Sayed, it was critical their book be released in the early months of the Biden presidency, with the COVID pandemic exposing the need for changes to American healthcare now more than ever. As he and Johnson write of the pandemic, the U.S. was facing “an absurd and tragic reality: Many of our hospitals and health centers were on the brink of financial collapse when they were needed most.”

El-Sayed and Johnson guide readers through a short history of the American health system and its inherent flaws, showing the “mediocrity” of a regime that is both more expensive overall and more regressive than those of peer nations. Despite the authors’ highbrow academic credentials (in addition to their MD’s, El-Sayed and Johnson were both Rhodes scholars) their prose is engaging and accessible, making the book an ideal read for both political junkies and the layperson interested in learning about healthcare. 

Much of the advocacy around Medicare for All has been about responding to an endless stream of attacks on the idea, and Johnson and El-Sayed work to effectively discredit just about every single one, providing talking points for single-payer proponents as well as strong arguments aimed at liberals still skeptical of the idea. El-Sayed and Johnson also deftly point out the many shortcomings of other progressive ideas for healthcare reform that their readers may be inclined to support. 

A public option, for instance, would keep in place many of the administrative costs associated with the current system, keeping large amounts of power and influence in the hands of private insurance companies. Other big reforms that focus on preserving private insurance may also lead employers to switch to another private plan or to the public option, as well, the authors write, setting the stage for another “if you like your plan, you can keep it” backlash.

In their more affirmative arguments for Medicare for All, El-Sayed and Johnson are similarly comprehensive, marshaling data to show that single-payer would not simply expand coverage, but could be vastly more efficient and cost-effective. A centralized, public insurance program would cut down on administrative expenses, while leading to cheaper drugs and services thanks to the system’s theoretical negotiating power. But the fight for Medicare for All is, as the authors and the program’s many supporters point out, about much more than improving balance sheets.

“[B]ehind the number crunching, Medicare for All expresses a new vision for economic justice,” El-Sayed and Johnson write.

Facing political reality

Along with making an ideological case for Medicare for All, El-Sayed and Johnson also attempt to get at the hot-button question of the moment for Democrats, which is how such a big reform package could ever be signed into law. Again, the authors must turn to their opponents, who have also been able to frame much of the debate around political feasibility.

Johnson and El-Sayed, like many progressives, see Republican stonewalling and obstinacy as a given and don’t waste time pining for the bipartisan days of old. Instead, they focus on those standing in the way of Democratic unity on healthcare, primarily the “twin barriers’’ of healthcare industry interest groups and conservative Democrats in congress. These two groups often work in tandem, the authors said, citing the meta-debate around Medicare for All’s hypothetical popularity. 

Electorally minded moderate Democrats regularly cite polls showing that Medicare for All is significantly less popular when it’s associated with higher taxes and Americans losing their current insurance, talking points that would be used in any industry campaign against the program and its supporters.

But as El-Sayed and Johnson point out, many of the same polls show support rebounding when single-payer’s positive attributes are also mentioned. One Kaiser poll found that support jumped to 54% when Americans were told Medicare for All would eliminate Americans’ private insurance but allow them to choose their own doctors, hospitals and medical providers. The lesson for the authors is that views on Medicare for All “will be deeply influenced by the coalitions lined up on either side of the debate—and by how they flex their power.”

Heating the waters for change

While prominent politicians like Sen. Bernie Sanders and Rep. Pramila Jayapal are publicly pushing for Medicare for All (both wrote forwards for “A Citizen’s Guide”) along with nurses’ unions and grassroots groups, the single-payer coalition still needs to grow, El-Sayed and Johnson write. Groups that could and should join up include physicians, labor unions, small businesses, and even large employers, whose combined and sustained efforts would be needed both to motivate political leaders and counter any industry opposition.

But even with those partners, proponents will have to overcome the political calculus in Washington, which is heavily weighted in opposition to single-payer. Johnson described HR-1, the proposed House legislation that includes voting rights protections, a prohibition on partisan gerrymandering and a slew of other electoral reforms—as “the single most important healthcare bill in congress right now.”

Narrow Democratic majorities and a president opposed to single-payer mean that Medicare for All’s moment is likely further down the road. Johnson described the next few years as a time for single-payer supporters to build power and momentum, while El-Sayed expressed his belief that support for single-payer is growing, and may happen faster than people expect.

“It’s like a pot of boiling water, and you heat it, and you heat it, and you heat it, and it doesn’t boil until all of a sudden it hits the right temperature and the thing starts boiling,” El-Sayed said. “The change toward Medicare for All is happening, the water is heating up. But it’s going to start boiling far faster than I think a lot of folks think, given where we are right now and the nature of the political conversation about healthcare right now.”