California and the rust belt: A health care bridge


Donald Trump upset the apple cart, pulling off a victory in the Electoral College by sweeping the Rust Belt states. He ran a brutal, hard-edged campaign on trade, jobs and resentment of immigrants. The shock has not yet worn off. 

Meanwhile, California went totally the other way, giving Hillary Clinton a 4 million-vote margin of victory that was bigger than even Barack Obama’s victory in 2012. 

California meets the Rust Belt.  A multiethnic state that is overwhelmingly Democratic where the economy has done well contrasted with a white, working-class and middle-class region in more isolated states with slower economies turning to the right. Like exploding planets, they are spinning off in opposite directions.

For many Jewish voters, who are concentrated in urban counties in big states such as New York, California, Florida, Illinois and Pennsylvania, there’s a feeling of being isolated in national politics. They are not alone. Throughout the Western world, from the U.K. to France to Poland to Italy, cosmopolitan, modernized urban communities where economies are dynamic are being challenged politically by non-urban, traditional working-class voters.

The difference is that in the United States, the metropolitan coalition commands a popular but not effective majority in our state-dominated system. California’s status as a blue stronghold, in a state where 1 in 8 Americans live, symbolizes the situation. California may guarantee popular vote majorities for Democratic presidential candidates for years to come and still be on the losing end in the Electoral College. Conversely, voters in the Rust Belt may find their hopes dashed if key programs on which they depend are reduced or eliminated. Hard as it is, some bridge building is called for.

I am hearing and seeing a lot of attempts to deal with the Rust Belt and with this shattering election. They vary from pop sociology, anger and contempt, to guilt and self-recrimination. Some say Trump’s voters don’t know their own self-interest and, if so, they deserve to lose their health insurance. Conversely, some are willing to toss out decades of progressive policies to win favor. None of this is ultimately productive.   

But there is another avenue that needs more attention. It starts with health care. The repeal of the Affordable Care Act (ACA) would affect both California and the Rust Belt. But to turn that impact into a bridge, California’s progressives will have to keep an open mind about the Rust Belt voters, including those who went for Trump.  

Never pick a fight with the voters — only with politicians. It would be better to fight with Trump and congressional leaders in Washington, D.C.  

In 2016, Democrats took a gamble by focusing the campaign on Trump and his appalling attitudes and utterances. Instead of drawing a contrast with an increasingly libertarian conservative movement that explicitly promised to shred major elements of the health care system, Democrats tried and failed to drive a wedge between the “unfit” Trump and, by implication, the fit conservatives. 

While all eyes were on Trump, who was making ambiguous noises about repealing the ACA but preserving its levels of access, House Speaker Paul Ryan was quietly laying plans to repeal the ACA, and to privatize Medicare to boot. Consider that eliminating the ACA makes Medicare more vulnerable, since its improved financial status is in part due to the ACA.

In truth, Democrats today are less focused on the daily issues of health care than on social issues. Those social issues are critical to modern politics and I could not imagine the Democratic Party without them. They have helped to build a popular majority, so that the modernizing Obama coalition, with its “identity politics” is far bigger and more consequential than Bill Clinton’s narrow, defensive alliance. But this is not enough without a down-to-earth message that goes beyond identity politics in a political system that provides extra boosts to the representation of nonurban, homogeneous states. 

California, where a great part of the Affordable Care Act’s implementation took place, and where its gains are at most risk, can lead the way. The same state-based system that frustrates popular majorities provides numerous pathways to resist and reshape change.

Retirement and health care security are great assets for progressives in American politics.  Protecting them starts with telling their story.  Voters tend not to believe campaign threats to their health care (“Look at this punim!  Would I kick my own mother off Medicare?”). The looming possibility of the loss of the Affordable Care Act may create an attentive audience.

Social Security, passed in 1935 and signed by President Franklin D. Roosevelt, became the vehicle for later expansions of health care. The Medicare and Medicaid laws signed by President Lyndon B. Johnson in 1965 were actually amendments to the Social Security Act.  President Richard Nixon further expanded Medicare coverage to those who are disabled and under the age of 65.  Medicare, a broad social insurance system like Social Security, became the link between retirement security and health care.

These concrete foundations helped cement the link between Jewish voters and the Democratic Party. My own family history tells a bit of that story. I was born in Washington, D.C., because my father, Israel Sonenshein, was an attorney in the Truman administration working in the Federal Security Agency, the precursor to the Department of Health, Education, and Welfare, that included Social Security. He helped draft a model law for the states to extend protection for those with mental illness, a group that had been left in the dark corners of American society. Naturally the New Deal was a big part of my family’s DNA. I watched LBJ on television in 1965 as he signed the Medicare law in Independence, Mo., with Harry Truman by his side, and learned that Johnson had handed Truman and his wife, Bess, the first two Medicare cards.

The ACA has become the largest expansion of health care coverage since Medicare. It has reached across racial lines, including communities of color and whites (many of whom voted for Trump), and added more than 20 million Americans to the insurance rolls. Except for the requirement to buy insurance, its provisions are very popular. While it does not enjoy the broad support of Social Security and Medicare, there is nowhere near a majority that favors repealing it without replacement, according to a recently released poll from the Kaiser Family Foundation.  

With the ACA, we are inching toward universal coverage. That goal, first articulated by Harry S. Truman in 1945, is visible on the horizon.

If Democrats are searching for a theme to tie together white, working-class voters in the Rust Belt and communities of color, they could start by fighting to protect the extension of health care through the ACA, and linking it to defending Medicare and Social Security against privatization. Just as Medicare linked Social Security to health care, the ACA links the broad social insurance of Medicare to the extension of health coverage to the hardest to reach precincts of America.

It’s time to stop talking about deplorables (unless they are in public office) and start fighting on behalf of voters. You never abandon the groups and communities and issues that are your base, but you find things that cross the lines. One thing leads to another, and more such issues will appear.

Don’t say, “I told you so” to Trump’s voters who may lose their health coverage. You can’t wait until these voters are nicer and more politically correct before fighting for them. And if they write letters to Trump, you can believe it will mean something. 

Don’t expect an immediately favorable response, because there are wide gulfs between communities, but it’s a start. Unlike in European democracies, our debates about government programs are not just practical. They get into perilous moral arguments about who is “deserving” and who is “undeserving,” even when someone is benefiting from a program. That is the hardest thing about the bridge-building I am proposing, and it will take time and patience.

Hold Trump accountable with the people who elected him. Let Red State Senate Democrats take the lead. It may be the only way they can survive. 

Fighting against an assault on health care expansion not only gets public attention, it is also a way to explain it. There are millions of people out there who still don’t know that Medicare is a government program. Every day that Congress debates the ACA or Medicare or Medicaid is an opportunity for civic education.

Health care has many civic benefits, including freedom to change jobs, and confidence that no catastrophe will destroy a family’s finances. In a nation beset with stress and worry, much of it economic, having health care in place may help us navigate the perilous days ahead. A more widely available health insurance system might even start to bring poor people back into the political system from which they have been massively absent.

The future of American politics is up for grabs, as electoral rules give extra advantages to areas of the country that are torn between popular conservative imagery and popular liberal programs. While a popular majority wants to preserve the tentative gains made in recent years, electoral rules make the imposition of the majority’s will a challenge. If the decades of progress made toward universal health coverage are lost in a fog of misinformation and distraction, there will be decades more to regret it.


Raphael J. Sonenshein is executive director of Cal State L.A.’s Pat Brown Institute for Public Affairs.