For the first time since Donald Trump became president — backed by Republican majorities in the Senate and House — Democrats will soon have significant political leverage to secure some of their policy priorities.

There’s a fresh opening for Democrats to enact policies including extending immigration protection for DREAMers, stabilizing health insurance marketplaces under the Affordable Care Act, extending funding for the Children’s Health Insurance Program (CHIP) and community health centers — and possibly more. Each of these matters, at one time or another, has had significant support from key Republicans.

This unusual and important opportunity arises because of the imminent debates over government funding for fiscal year 2018 and over extending the nation’s debt ceiling. Although these bills are expected to follow separate tracks, failure to do both of these things in a timely way — this December for the federal funding bill and not long after that for the debt ceiling extension — could shut down the government.

Most Republicans won’t want to risk a shutdown, and “reconciliation” isn’t an option

President Trump sometimes blusters about the desirability of shutting down the government, but doing so would cause great peril for Republicans. Given their unified control of the government, Republicans would surely take most blame if national parks close, Social Security checks are withheld, Medicare and Medicaid payments aren’t made, and military active-duty pay is delayed. A government shutdown and a default on US legal obligations would also create a tailspin in the stock and bond markets.

Such a shutdown would undoubtedly place Republican congressional majorities at major risk during the 2018 elections — and, despite their bravado, Republicans know this.

Until recently, House Speaker Paul Ryan (R-WI) and Senate Majority Leader Mitch McConnell (R-KY) have only consulted fellow Republicans on their top legislative priorities: ACA repeal and tax changes. Both of those measures, unlike fiscal year funding and the debt ceiling increase, have been authorized to use the unusual so-called reconciliation process that enables them to pass those bills in the Senate with only 50 votes. (The relatively rare reconciliation process, only allowed in 2017 for health and tax legislation, prohibits Senate filibusters.)

Reconciliation made it possible to ignore Democrats when Republicans sought to repeal the ACA and to decimate the safety net Medicaid program. Thankfully, that approach failed. Now Republicans are similarly going it alone trying to adopt major tax changes with a proposal offering huge windfalls to the rich and large corporations while ballooning the deficit.

But funding of this fiscal year’s budget and debt ceiling bill have a much different dynamic, for two reasons. First, passage of the bills is likely to require 60 votes in the Senate, and Republicans only have 52 members. At least as significantly, many Republicans have a chronic aversion to vote for an increase in the debt ceiling — and, as history shows, a large portion of the party’s most conservative members will not do so. This means that substantial Democratic votes will be needed for passage of the debt ceiling in both the Senate and House. 

So the Democrats have leverage. How should they use it?

Instead of being mere supplicants, therefore, Democrats will have real clout. But they will have to play their cards carefully.

Measures like protecting the DREAMers, promoting ACA market stabilization, and funding CHIP and community health centers have not yet moved forward. Even though they enjoy significant bipartisan support, they have been stalled, or subjected to unacceptable conditions, by hardcore right-wingers — at least when they were presented as standalone bills.

These measures, however, have a far better chance of being adopted if they are part of the upcoming “must-pass” bills like the fiscal year 2018 budget and the debt ceiling extension. And their inherent popularity will put Democrats on solid political grounds when Republicans inevitably seek to shift the blame to Democrats if a shutdown looms.

Protecting the DREAMers

DREAMers — the Deferred Action for Childhood Arrivals (DACA) recipients — were given limited but crucial protections by the Obama administration in June 2012. Through a memorandum issued by the Department of Homeland Security, undocumented individuals who entered the country as minors became eligible to receive renewable two-year periods of deferred deportation protection and became eligible for work permits. Altogether, approximately 800,000 youth enrolled in the program, and they are a very sympathetic group.

In September, President Trump denounced the DACA program and indicated he would phase it out in six months, thereby making the DREAMers eligible for deportation in March 2018. But then came the waffling. In response to criticism, Trump tweeted that the six-month delay would give Congress an opportunity to legalize DACA-related protections through legislative action. He also ambiguously indicated that he would “revisit this issue” if Congress failed to act.

During a dinner meeting in September with Senate Democratic leader Chuck Schumer and House Democratic leader Nancy Pelosi, Trump indicated he would be willing to sign DACA protection legislation even if it did not include funding for his signature wall along the Mexican-US border. And he called the DREAMers “good, educated, and accomplished young people.”

Since then, Trump has backtracked once again. But he seems genuinely uneasy with the prospect of moving aggressively against the DREAMers — as surely do many Republican members of Congress. Including the DACA continuation as part of must-pass legislation would give them political cover while providing much-needed protections to youthful immigrants.

Stabilizing health insurance marketplaces

Although Republicans have failed in their repeated attempts to repeal the ACA, President Trump is sabotaging its implementation — from radically shortening the open enrollment period to radically reducing ads informing Americans about ACA coverage opportunities, to, most significantly, ending cost-sharing reduction (CSR) payments to insurers. These CSRs underwrite discounts for low-income people who can’t afford insurance deductibles and copayments. Without the CSRs, insurers predictably increased premiums for people in the marketplaces.

These developments brought together Sens. Lamar Alexander (R-TN) and Patty Murray (D-WA), the chair and ranking minority member of the Senate Health, Education, Labor, and Pensions Committee, to devise a plan to stabilize insurance marketplaces. The plan includes restoring CSR payments for two years and provides greater flexibility for states to experiment with some aspects of ACA implementation — a Republican priority.

Although the Alexander-Murray bill has attracted at least 60 supporters in the Senate, and although it would reduce the ACA’s costs by bringing down premiums, its enactment is far from certain. President Trump encouraged the senators’ collaboration but hasn’t endorsed the bill. Attaching it to one of the must-pass bills might be a deal that President Trump would have difficulty saying no to.

Extending funding for CHIP and community health centers

Finally, there’s the Children’s Health Insurance Program. Thanks to CHIP, today’s uninsured rate among children is at a historic low — less than 5 percent. (That’s a third of the figure in 1997, when the program started.) It has always enjoyed strong bipartisan support, starting with its original sponsorship by Sen. Orrin Hatch (R-UT) and former Sen. Edward Kennedy (D-MA).

Similarly, community health centers enjoy bipartisan accolades and provide critically important care, serving approximately 24 million patients in nearly 10,000 medically underserved communities.

Unfortunately, federal CHIP funding expired on September 30. If funding is not reinstated soon, states will begin to terminate health coverage for their low-income children. The Health Centers Fund, one of two key sources of federal health center support, also ended on September 30, a move that could lead to closures of 2,800 centers.

Although there continues to be strong bipartisan support for extending CHIP and health center funding, such legislation is stalled. The key impediment is House Republicans’ determination to pair such funding with ACA-related cuts, especially the Prevention and Public Health Fund that, among its health services, vaccinates children and fights the opioid epidemic. Inclusion of CHIP and health center funding extension to the earliest must-pass bill would help to break the stalemate.

Democrats should be steadfast about using their new and unusual leverage. They may even be able to add one or more measures, perhaps including expanded aid to Puerto Ricans afflicted by Hurricane Maria, including support for the island’s financially strained Medicaid program.

But DACA, ACA stabilization, CHIP, and community health center funding are where to start. They’re the bargaining chips that have the greatest bipartisan support. These are the policies that Republicans would be hardest-pressed to oppose, and Democrats should push them hard.

In a time when Democrats have few chances to go on the offensive, this opportunity must not be squandered.

Ron Pollack served as the founding executive director of the consumer health organization Families USA for more than three decades, and he is currently the organization’s chair emeritus. He played a leading role promoting the adoption and implementation of the ACA as well as the expansion of Medicaid. The opinions expressed in this article are his own. Find him on Twitter @Ron_Pollack.

The Big Idea is Vox’s home for smart discussion of the most important issues and ideas in politics, science, and culture — typically by outside contributors. If you have an idea for a piece, pitch us at thebigidea@vox.com.

Yesterday, Senator Bernie Sanders and approximately a dozen other Democratic senators introduced a single-payer bill that is intended to become a focal point for discussion about the future of US health care.

Coming less than two months after progressives and America’s families won a huge victory by preventing GOP efforts to repeal the Affordable Care Act and to decimate Medicaid, the bill marks a new, less defensive Democratic position. Vigilance and unity are still needed to protect against attempts to undermine recent historic health improvements. But this bill aggressively advances the debate over how best to advance the progressive goal of achieving high-quality, affordable health care for everyone. 

Maybe we should hit pause before we get on this bandwagon. The overriding goal among progressives is to ensure that health care becomes a basic human right — truly and affordably available for all, irrespective of income, race, ethnicity, gender, sexual orientation, immigration status, and geography.

But there are several paths to universal health care coverage. Single-payer can be one of them — but it isn’t the only one. Indeed, many countries have reached the goal using methodologies other than single-payer, including varying blends of public and private coverage.

Too many progressives and others fail to distinguish between “universal coverage” and “single-payer.” The terms are used interchangeably in private conversations and in the national arena.

As we consider the most effective strategy for achieving universal coverage, progressives should keep two admonitions in mind. First, we must not conflate our foremost health care goal (universal coverage) with competing pathways toward achieving that goal. Second, recognizing that our differences are about strategy and not final goals, the dialogue should be undertaken with mutual respect.

The strategic impediments to the single-payer pathway

Nations that have achieved universal health care coverage chose their distinctive pathways based on a host of factors, including cultural, historical, and political contexts. We must pay attention to such factors in the American context, too.

America’s unique history and politics make the successful promotion of a single-payer system an unlikely pathway to universal health coverage. There are three reasons. The first involves the inevitable strong and well-funded opposition of special-interest groups.

Since the 1930s, associations representing the pharmaceutical, insurance, hospital, physician, and medical-device industries have consistently and vehemently opposed attempts to reform health care through any approach perceived as leading to single-payer. Their only defeat on this front occurred in 1965, after President John F. Kennedy’s assassination and the Barry Goldwater electoral fiasco, when Medicare and Medicaid were enacted at a time of huge Democratic majorities (68-32 in the Senate, 295-140 in the House). Such Democratic dominance of national politics seems unlikely in the foreseeable future.

The second political impediment is the potential backlash to the cost of single-payer, and how it will be financed. Although a single-payer system would almost certainly be more efficient than the continuation of a multi-payer system, such a system would require a tax increase of a scale likely to cause the public to balk — especially when anti-tax groups mobilize.

The size of the necessary taxes cannot yet be determined, since it would depend on the precise design of the new system (such as the benefits covered and the portion of those benefits paid through consumers’ premiums, deductibles, and copayments). But the failed attempt to establish a single-payer system in Vermont, perhaps the most progressive state in the union, gives a sense of the challenges ahead.

The cautionary tale of Green Mountain Care

Former Gov. Peter Shumlin and many in the mainly Democratic state legislature crusaded for a single-payer system dubbed Green Mountain Care. But, after four years of tireless efforts, Shumlin reluctantly ended his quest when his analysts concluded it would require an 11.5 percent payroll tax plus a sliding-scale income tax that peaked at 9.5 percent. Polls told him that even the state’s mostly liberal constituents were unlikely to embrace single-payer at that price.

Finally, as both Democrats and Republicans have now learned, once people have health care coverage, they are sensitive about efforts that might take it away or potentially diminish its quality. Today, approximately half of the US population receives health coverage through the workplace. If that coverage is replaced with a single-payer system, workers will be vigilant about making sure the new coverage is at least as good as what they had before.

Will the new coverage be as comprehensive? Will they pay more in premiums, deductibles, and copayments than they do today? Will they get to keep their doctors? The answers to each of these questions will vary based on the design of the new single-payer plan and on people’s current coverage.

While there likely would be many “winners” under a new single-payer system, there no doubt would also be a significant number of people who perceive themselves as “losers.” The latter would become a very vocal and active oppositional force — probably more vocal than the “winners.”

Asking people to pay higher taxes for coverage they fear is inferior (and in a few cases is inferior) is a recipe for a backlash.

The viable alternatives to single-payer

Concluding that it is highly unlikely that a single-payer system can be adopted in the foreseeable future does not mean that we should give up on our goal of universal coverage. Quite the opposite! There are other, more politically achievable, pathways.

As long as Democrats don’t hold unusually large majorities in Congress, plus the presidency, the pathway to universal, affordable health coverage won’t be through one omnibus new law. We must have the persistence, and the commitment, to take incremental steps toward that goal.

Incrementalism should not be considered a four-letter word. It produced numerous expansions and improvements in Medicaid, which now covers more than 70 million people. It led to the Children’s Health Insurance Program (CHIP), which resulted in historically low uninsured rates among children. It added much-needed prescription drug coverage for seniors and people with disabilities in Medicare. It added home and community-based care as an alternative to nursing homes. And it helped people with preexisting conditions combat insurance company discrimination.

As we consider the next incremental steps to promote, we should focus on expanding health coverage to the nearly 30 million who remain uninsured, and we should strive to lower health costs while improving quality of care. The following goals meet those criteria.

• Expanding Medicaid in 19 states: Now that Republicans have at least temporarily lost their fight to repeal the ACA, and since extraordinarily generous federal subsidies remain to expand Medicaid, progressive advocates should renew their efforts to secure added coverage for low-income adults in the 19 states that have not yet approved the expansion. Of the 31 states that already expanded Medicaid, 18 are currently led by Republican governors. Since refusing federal money is unlikely to lead to ACA repeal at the national level, we should now expect other state Republican leaders to be more amenable to expansion, too. Activists and voters should push them in that direction.
• Providing coverage for immigrants: Because of the ongoing national controversy about immigration, it is unlikely that federal legislation will extend health coverage to immigrants. But there are opportunities to do so at the state level. California, the District of Columbia, Illinois, Massachusetts, New York, and Washington already use state funds to cover undocumented children through Medicaid. In California, approximately 200,000 children have gained coverage through this expansion, and many more are eligible. Now the state is debating extending such coverage to undocumented adults. Progressives elsewhere should push their representatives to make similar efforts.
• Fixing the so-called “family glitch”: People with access to affordable employer-sponsored health insurance are ineligible to receive ACA premium assistance in the individual marketplace. Unfortunately, due to an ACA drafting error, “affordability” is gauged by examining what it would cost the worker to cover him or herself at work — not the coverage costs for the worker’s family. As a result, many families who ought to be eligible for subsidies are not getting them. This is an acknowledged, unintended mistake, and activists should work to have it fixed. This would help millions.
• Extending CHIP: Under current law, funding for this popular and effective program, which provides health insurance for low-income children, is only authorized through September 2017. The program was adopted on a bipartisan basis and is very popular among Republican as well as Democratic governors. Progressives should push hard to secure a funding extension as soon as possible.

Aiming to curb costs could create strange political bedfellows

Similarly, progressives should work in concert with the diverse payers of health care to promote moderation of fast-rising health care costs while improving quality of care. Our objectives should include:

• Paying for quality, rather than quantity, of health care: Our nation’s fee-for-service model — used in private as well as public health coverage — is extraordinarily wasteful and does not beget high-quality outcomes. Much experimental and analytic work still needs to be done to determine how we should most effectively and efficiently pay for quality of care. But progressives should push to hasten the testing and deployment of the most promising new models.
• Reducing prescription drug prices: One out of every 10 dollars spent on health care now pays for prescription medicines, and the proportion is growing. Drug prices rose by more than 11 percent in 2016 and are projected to rise by almost 12 percent this year. PhRMA’s lobbying clout remains prodigious, but fast-rising drug prices are creating a public and health-sector backlash. The time may be ripe for ending the prohibition that prevents Medicare from bargaining for lower drug prices.
• Remedying anti-competitive health system market domination: Geographic areas with near-monopolistic concentrations of health systems result in comparatively high health care prices. Public policy should strive to end such concentrations. It’s a goal that both progressives and conservatives can embrace.
• Promoting a “public option”: In too many locations across the country, the ACA marketplaces only have one insurer. This lack of choice has been roundly criticized by Republicans, deservedly so because the lack of insurer competition tends to result in higher premiums. To correct this problem, progressives should continue their quest to allow a public plan to be established in such low-competition areas.

All of these incremental efforts would require hard and tenacious efforts. But they are potentially achievable in the near future, and they would move our nation considerably closer toward the goal of high-quality, affordable health coverage for all.

Over time, there’s no reason incrementalism can’t get us all the way to 100 percent coverage. Single-payer isn’t the only route to that goal. In the foreseeable future, the step-by-step approach is the strategy progressives should pursue.

Ron Pollack served as the founding executive director of the consumer health organization Families USA for more than three decades, and he is currently the organization’s chair emeritus. He played a leading role promoting the adoption and implementation of the ACA as well as the expansion of Medicaid. The opinions expressed in this article are his own. Find him on Twitter @Ron_Pollack.

The Big Idea is Vox’s home for smart discussion of the most important issues and ideas in politics, science, and culture — typically by outside contributors. If you have an idea for a piece, pitch us at thebigidea@vox.com.

As the clock ticks nearer to the day when President Trump and the Republican Congress move to repeal the Affordable Care Act, a struggle looms with a simple, elemental force that cares not for slogans, spin, or bluster — and that is the troubling arithmetic encompassed in the Republicans’ expected repeal bill.

More specifically, the arithmetic focuses on whether Trump and congressional Republicans will have the fiscal ability to pay for a “great” replacement to the repealed ACA. (The president-elect announced this weekend, dubiously, that he is putting the finishing touches on just such a plan.) This is because Republicans, in their past ACA repeal bills and their expected new repeal bill, include large, regressive tax cuts — tax cuts benefiting couples with incomes in excess of $250,000 a year as well as health insurers, pharmaceutical companies, and medical device manufacturers.

The total cost to the federal government of these tax giveaways to wealthy people and interest groups is estimated to be almost $600 billion over the next decade — which, when included with other fiscal measures in the repeal bill, would result in losses of federal revenues approximating $1 trillion. As a result, the Trump administration and congressional Republicans would have wholly inadequate resources for a replacement that prevents many millions from losing health coverage.

This revenue played a key role in underwriting the costs of expanded health coverage. It enabled coverage expansion to 20 million people who were previously uninsured. It helped pay for significant tax credit premium subsidies for people buying private insurance as well as for expansion of the safety net Medicaid program.

It’s simple: Less money means less coverage — and worse coverage

When this revenue is lost, a combination of problems will occur for the people who recently gained coverage — as well as many others. It will most likely mean that Trump and congressional Republicans will be bereft of resources to prevent wholesale losses of coverage. For those who retain coverage, it means any replacement legislation will result in coverage that is relatively skimpy and comes with higher premiums, deductibles, and other copayments — which, for many, will be unaffordable.

To include these tax giveaways in legislation eliminating premium subsidies for moderate-income families and ending Medicaid expansion for the poor is a clear example of Robin Hood in reverse. And it’s not a temporary move, despite the rhetoric. This is not a situation in which bad programs and rules are removed in preparation for the arrival of a better suite of policies. Whether as a conscious strategy or as an unintended consequence, the withdrawal of substantial revenue from the federal government makes it impossible that the “replace” legislation can match, let alone improve on, the ACA’s successes.

This is an arithmetic problem that won’t likely be overcome.

Rhetoric that does not square with budget reality

President-elect Trump is apparently aware of this. During a television interview with Dr. Oz back in September, Trump was asked what he would do for people “who fall through the cracks” following the repeal of the ACA. Trump said public funds would have to be made available for their health care — likely through Medicaid.

“We’re going to take care of those people,” Trump said. “We have no choice. We’re not going to let people die on the streets.” In an interview with the Washington Post this weekend, Trump swore he would provide “insurance for everybody,” while offering precious few details about funding or logistics.

These are fine sentiments. But the budget arithmetic problem belies it. If Republicans give away the precious funds dedicated to the ACA in a transfer of wealth from the bottom to the top, there will be few resources left to help the millions of people who will lose coverage following the ACA’s repeal.

Arithmetic is a crucial part of governance. Republicans now have total control over the legislative and executive branches. They can govern by subtraction, and take health care away from millions with no practical plan or resources to restore it. Or they can govern by addition, and make sure they have ready a replacement plan for the ACA that will build on its success, make it even stronger — and with an ability to pay for it.

A great nation like ours surely needs a more robust approach to health care than simply asserting no one should die in the streets — while at the same time distributing money away from the part of the government that lets us accomplish that worthy goal. We should dedicate the resources to ensure that everyone has access to quality, affordable health care.

Ron Pollack is founding executive director of Families USA, the national organization for health care consumers.

The Big Idea is Vox’s home for smart, often scholarly excursions into the most important issues and ideas in politics, science, and culture — typically written by outside contributors. If you have an idea for a piece, pitch us at thebigidea@vox.com

Watch: Repealing Obamacare could change millions of lives