This article by NESRI Campaign Manager Ben Palmquist was originally published in Jacobin.

The Congressional Budget Office has scored Republicans’ American Health Care Act, and the picture is bleak. If the House bill passes the Senate, it would take health insurance away from twenty-three million people, reduce others’ coverage, and further raise premiums and out-of-pocket costs on older people and those with more medical needs.

These attacks, which target poorer, older, and sicker people and women with almost surgical precision, would fall on tens of millions of people are already in a dire situation. Nearly thirty million people are uninsured, tens of millions more have insurance but still can’t afford needed care, health-care costs are rising unabated, crushing medical debt is forcing people out of their homes, and tens of thousands of people die every year because the insurance system denies them lifesaving care.

The root of all of these problems is the private insurance system, which by design prioritizes insurance companies’ profits over human lives. Moving to a national, publicly financed, single-payer insurance system would, in one fell swoop, solve all of this. Yet since the days of Harry Truman, no one has been able to muster the power to overcome the opposition of the insurance industry. Leaders like Congressman John Conyers and Senator Bernie Sanders who back universal health care are the exceptions that prove the rule: market-fundamentalist ideologies, lobbyists, and campaign donors still hold tremendous sway over both parties in Washington.

Winning universal health care will take a mass people’s movement, and building a movement means joining together with others where we live and work. The road to universal, publicly financed health care thus runs through the states. And no state is better positioned to lead than California.

States’ Golden Opportunity

States have a moral obligation as well as a keen economic interest in improving public health and arresting the insane run-up in prices that insurance, drug, and hospital corporations charge to residents, employers, and state governments. Now, with widespread anger at soaring costs, Congress’s anti-health rampage, and a growing desire for government involvement in health care, the moment is ripe to build a new popular consensus around universal health care as a cornerstone for a just and healthy society.

Just about every state has an active and organized grassroots campaign for universalhealth care. New Yorkers just passed a bill through the assembly and are gaining ground in the senate, and both Vermont and Colorado have come close to creating universal, publicly financed health care in recent years.

Yet California’s political alignment and scale make it unique. Democratic officials hold supermajorities in both houses as well as the governor’s mansion, and are eager to portray themselves as the vanguard of the resistance to Trump. The powerful Healthy California campaign, which is leading the state’s fight for universal health care, has 150 coalition members who together boast four million members. And with its enormous economy and tax base, shifting health-care financing from private premiums to public taxes is an easier lift for California than for smaller states.

Now, with the Healthy California Act, which passed the state senate on June 2, the Golden State has a chance to prove itself. But victory is hardly assured: the insurance industry and its allies are hugely powerful, and nowhere has the Democratic Party yet taken a stand for human health over the interests of its corporate donors.

To succeed, Californians must overcome two pivotal challenges that have defeated every attempt at universal health care in recent years. They must protect against the opposition’s attempts to divide their coalition, and they must overcome and supplant anti-tax, anti-government rhetoric with a fundamentally different vision.

Inclusion and Exclusion

The question of who is included and who is excluded has always shaped American health-care policy. In our patchwork insurance system, whether or not we get care depends on our employment status, immigration status, parental status, pregnancy, relationship status, military service, place of residence, age, income, and our particular medical needs. Tens of millions of us don’t make the cut.

The beauty and power of universal health care is precisely that it includes everybody, yet if the recent universal health-care campaigns in Colorado and Vermont are any guide, Californians should expect the corporate opposition — and perhaps even elements of the Democratic Party — to raise questions about exclusion in order to fracture and divide their health-care coalition.

This past November, Colorado voters resoundingly voted down Amendment 69, a ballot measure that would have created a statewide universal, publicly financed health-care system called ColoradoCare. One of the industry opposition’s key tactics was to raise concerns over whether the initiative would cover reproductive care. Colorado’s constitution bans public funding for abortions, and because Amendment 69 did not explicitly override the prohibition, opponents argued the ban would stand, prohibiting ColoradoCare from providing comprehensive reproductive health care.

In other words, the opposition used abortion not to mobilize the anti-choice right, but to fracture and divide the Left, and they succeeded. NARAL publicly opposed the initiative, and their perverse framing of ColoradoCare as anti-women’s health caught the Yes campaign flat-footed. It also gave weak-kneed Democratic officials an excuse to oppose ColoradoCare, which they did in droves.

Had women’s and reproductive justice organizations, including organizations representing and led by women of color, immigrant women, working class women, and LGBTQ people, been a key part of developing ColoradoCare, things could have been different. Those organizations would have made sure that reproductive health was protected by the amendment, and Colorado could have had a real chance at building a winning coalition.

In contrast, the Vermont Workers’ Center’s “Healthcare Is a Human Right” campaign offers California and other states a model for how to inoculate against divide-and-conquer tactics.

In 2011, Vermont became the first — and, as yet, only — state to pass a bill for universal, publicly financed health care. Though Vermont’s Act 48 critically neglected to include tax financing to make the proposed system a reality, it remains on the books and is, to this day, the biggest victory for universal health care the United States has yet achieved.

But the law was thrown into jeopardy just days before it passed when a pair of senators, a Democrat and a Republican, introduced an amendment that would have stripped undocumented immigrants out of the bill. Fortunately organizers had prepared for this moment and were ready.

Working closely with their allies at immigrant rights organization Migrant Justice, the Vermont Workers’ Center held a huge rally at the State House, packed committee hearings, and got the Democratic senator to back down. The sponsors withdrew their amendment, and Act 48 went on to pass with language that included all Vermont residents regardless of their immigration status.

The lessons from these tales are clear. Californians must unite around a clear, unflinching commitment to include absolutely all care and all residents. Just as importantly, Californians must back up that commitment by ensuring that communities who are commonly excluded from care have a leading role in the campaign and reshaping the health care system.

So far, all signs in California point in the right direction. The language of the Healthy California Act is unequivocal in its inclusion of all residents regardless of immigration status, and the law guarantees access to truly comprehensive care. Senator Ricardo Lara, a staunch advocate for immigrant rights, is co-sponsoring the bill, and the Healthy California campaign is modeling a commitment to universal inclusions through both its messaging and its membership.

Nevertheless, other states’ experiences suggest that it is only a matter of time before opponents attempt to water down California’s law and divide its coalition. Breitbart is already beating its xenophobic drum against the bill, and more subtle ploys are already emerging that aim to pit medical professionals and people with employer-sponsored insurance against the rest of the state. Californians must reject these divisive narratives. They must make clear to legislators that there is zero room for exclusion.

Reclaiming the Public Narrative

The second key challenge to realizing universal health care is anti-tax, anti-government rhetoric. This ideology, which is deeply racialized in American politics, has profoundly shaped both parties’ agendas and constrained the entire political discourse for decades. By strategically peddling a pro-market, anti-government agenda through think tanks, media companies, and politicians for their own gain, billionaires like the Koch brothers have masterfully controlled what is deemed politically possible or even worthy of conversation.

Economists from UMass Amherst estimate that Healthy California would provide comprehensive care to everyone in the state for less money than residents, employers, and the state pay now, but California’s business and political elites are already framinguniversal health care as a tax increase. The mainstream media, which is largely funded by ads placed by those same business elites, is playing right along. Reporters and editorial boards have selectively focused on the shift of health-care spending into the public budget while downplaying or entirely ignoring the elimination of private premiums and deductibles, the incredible potential to meet unmet human health needs, and the ability to do all this for a smaller share of the state’s GDP, 15 percent, than the 19 percent of GDP the United States already spends on health care.

Again, Colorado and Vermont offer crucial lessons. In Colorado, the corporate opposition campaign ran ads and used public messengers to frame ColoradoCare as a $25 billion tax hike and as interference by politicians and government bureaucrats in people’s lives. They were wildly successful. In Vermont, Governor Peter Shumlin signed Act 48, but then three years later turned around and used anti-tax austerity framing to justify not following through on public financing.

Ignoring the high health-care costs that employers, families, individuals, and the public already pay as well as the urging of over one hundred economists, his own financing plan (which would have saved the bottom 93 percent of families money), and an even more progressive financing plan from the Vermont Workers’ Center and the National Economic and Social Rights Initiative, Shumlin said that public financing was “not affordable at this time.”

Shumlin used the logic of austerity to justify his opposition to the proposal, rhetoric we will continue to hear both Democrats and Republicans use to justify their opposition to such plans. But there are signs its stranglehold is loosening. Bernie Sanders’s success in the primaries, growing popular support for socialism, and, in its own perverse way, the election of Donald Trump all reveal a widespread desire for a more active public role in shaping the economic and social life of the country.

To be sure, there are deep divides over who should benefit from public action and redistribution. But while this discord presents a challenge to struggles for justice, it also presents a tremendous opportunity. The solution is not to shy away from tough conversations about taxes and the role of government, but to lean into them.

Health care offers the perfect opportunity to upend the neoliberal market-fundamentalist ideology that has long dominated American politics. People are turning out to town halls in droves and demanding more public involvement in health care, not less. Polls consistently show that a large majority of people recognize that governmenthas an obligation to make sure that everyone can get care, Bernie Sanders’s call for “Medicare for All” helped make him the most popular politician in the country, and the insurance and drug industries have approval ratings even lower than Donald Trump. The public is way ahead of both parties.

The Healthy California campaign has concrete ways for Californians, and the rest of us, to get involved. We can reveal the failures of the private insurance system by sharing our stories. We can call our legislators to ask them to support the Healthy California Act and to stand against the exclusion of anyone in the state; we can donate money to the Healthy California campaign and to movement organizations where we live; we can go to a local meeting together, join a lobby day in Sacramento, or pool donations to Healthy California.

In California, we all have a tremendous opportunity to win universal health care, but the future hinges on what we do now.