Medicare for all is mainstream now.

The U.S. healthcare system is expensive, inefficient, and full of gaps. Americans rank 33rd among 35 developed countries in longevity.

U.S. Senator Ron Wyden says it's time to stop trying to repair a flawed system. It's time to reimagine it.

Wyden says we need "Medicare for all."

Wyden was in Medford, Oregon, on Monday finishing up field hearings on health care in America. Health care professionals and patients testified to what was wrong.

-- Hospitals were closing because they couldn't get paid enough to provide the services they offer.

-- Rural areas and small cities couldn't recruit physicians to practice there, forcing people to travel long distances for care.

-- Patients couldn't get insurance approval for life-saving drugs.

-- Mental health care was hard or impossible to access.

-- Uninsured and underinsured people delayed preventive care, leading to higher costs when treatable problems became critical.

-- Health insurance premiums have become unaffordable, made worse by the cuts legislated in the "Big Beautiful Bill."

-- Health care workers are unhappy. We train enough nurses, but we still have shortages, because people leave the profession.

-- Physicians spend their time and energy on billing, coding, and negotiating with insurance companies rather than seeing patients.

Wyden's support for Medicare for all is a shift in the political environment within the Democratic Party. This looks like another iteration of Ernest Hemingway's observation on bankruptcy: it happens gradually, then suddenly. 

In 1993, First Lady Hillary Clinton tried to shape a health care program to provide universal coverage — the Health Security Act, known as "Hillarycare." It faced strong opposition from lobbyists and Republicans, and it contributed to a disastrous 1994 midterm election defeat for Democrats. Barack Obama's 2008 election brought Democratic majorities, which made enactment of the Affordable Care Act possible in 2010. It was a patchwork mixing private health insurance, Medicare, Medicaid, and private insurance bought through exchanges. Joe Biden famously called it a "big fuckin' deal," but the program was new and complicated, and the rollout was ragged. The result was another midterm wipeout for Democrats in 2010. Republicans ran on platforms of "repeal Obamacare."

But the political tides were shifting. Voters, including Republicans, liked the provision that allowed businesses and their uninsured employees to buy health insurance through the exchanges. They liked the provision that required insurers to accept customers with pre-existing conditions — a provision that freed people who had stayed in unsatisfying jobs because if they left they would be uninsurable and at risk of catastrophic medical expenses.

President Trump did not argue that Americans should be self- reliant and take their chances in an unregulated marketplace. He said he supported a bigger, better, cheaper health care program. Trumpcare would be better than Obamacare. Trump is selling wishes, not a program; he has never offered an alternative plan of his own. But Republicans now understand that there needs to be some kind of national program: either the flawed Obamacare they oppose, or some magical better one that they are forever positing.

Bernie Sanders' 2016 campaign moved the ball forward with his call for Medicare for all. It was simple to explain. Medicare already existed, and most participants liked it. Republicans derided it as unaffordable socialism. Democrats were divided. Labor unions, some of which had negotiated excellent health plans, opposed it, because their special paid-for benefit would become available to everyone. Moderate Democrats looked for a middle ground. Pete Buttigieg called for "Medicare for all who want It," and that became the middle-ground position among Democrats. The middle-ground position presumed something inevitably complicated: a mix of private plans, union-based plans, and needs-based plans, with a variety of subsidy formulas designed to keep plans affordable for both taxpayers and the insured.

Wyden: Centered, but ideologically left

Ron Wyden's adoption of the phrase "Medicare for all" signals a shift in what will become commonplace Democratic policy. Wyden is a liberal — by some measures, roughly the 10th-most- liberal U.S. senator — but he has served in the Senate for decades and risen to ranking member of the powerful Senate Finance Committee. Wyden works effectively with Democratic colleagues and Republicans to get legislation through the committee and passed into law. In that sense, Wyden is the establishment: a senator who operates within the group that reflects majority opinion. He isn't an outsider insurgent; he is in, and creates, the majority.

Wyden's move signals a change in the Overton window, that measure of whether an idea is revolutionary, merely edgy, or mainstream. Medicare for All is mainstream for Democrats now. 

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