Earlier this month, a reporter asked Nancy Pelosi if Democrats should run on a single-payer platform in 2018. Pelosi said no – that the "comfort level" for a government-funded health care system is just "not there yet" among a broad enough base of Americans.
Pelosi might feel differently had she been at Rep. Tom MacArthur's town hall in Willington, New Jersey, Wednesday night. Over four-and-a-half grueling hours, the moderate Republican responsible for resurrecting the American Health Care Act was pilloried by his constituents, who argued forcefully, and repeatedly, in favor of a single-payer system.
New Jersey's third congressional district runs the width of the state, from Pennsylvania to the Atlantic Ocean. A deep V divides it into two nearly distinct areas whose bottom corners just barely touch at the center. The eastern part of the district lies in Ocean County, home to the state's wealthiest enclave, Mantoloking; the western half sits squarely in Burlington County. A sandy swath of land known as the Pine Barrens runs between the two.
Willingboro Township, just across the Delaware River from Northern Philadelphia, is part of Burlington County. It's 73 percent black, and has a per-capita income of less than $22,000. It is not Tom MacArthur's core constituency. As the congressman notes in his opening salvo Wednesday, Trump picked up just nine percent of the vote in Willingboro, while he himself "crushed it with 12 percent."
"In this part of the district, there are 40,000 more Democrats than Republicans," the congressman says. "But when I drive across the Pine Barrens tonight to go home, and I get out on the other side, I'll be in a [county] that Donald Trump won by more than 90,000 votes. ... I have to represent both sides: this side, and also the other side, where our president won two-to-one – two-to-one!"
("They've got no brains in Ocean County!" someone yells from the audience.)
MacArthur thinks of himself as a centrist, but this session he's voted with Trump 93 percent of the time. The most important of those votes was the one he cast last week, in favor of the GOP plan to repeal and replace Obamacare. He didn't just vote for it, either – he wrote the amendment that got the bill through the House.
MacArthur knows the insurance industry well. He likes to tout the fact that he made just $13,000-a-year in his first job as an insurance investigator in the New York City housing projects. He spent three decades in the field, becoming very rich (his net worth was estimated at more than $50 million in 2014), before retiring as CEO of an insurance company in 2011 to run for mayor, and then Congress, in New Jersey.
Like virtually everyone else, he's had experiences on the other side of health insurance companies too. His mother died of cancer, without insurance, when MacArthur was just 4 years old; it took his dad years to pay off the bills. His oldest daughter Grace, born with severe mental and physical handicaps, accumulated more than $1 million in medical bills before she died at age 11.
It's a testament to just how poisonous MacArthur's decision to help Trump push the AHCA through the House was that, here in his district, his impatient constituents won't even let him finish a story about the death of his special-needs daughter before interrupting and urging him to take their questions about the Obamacare replacement bill. "We've heard about your daughter! Get to the questions!" audience members shout. "Write a book!"
He does take questions – hours of them – staying until every one the nearly 300 people who managed to get inside the community center has a chance to ask one. (Hundreds more are left outside, standing in line or brandishing signs or skeletons or cardboard tombstones in protest. A biplane does loops overhead trailing a sign that reads "MACARTHUR: TAX CUTS FOR THE 1%; NO CARE.")
More than anything else, the constituents who've made it into the room – and MacArthur's staff checked to make sure they are constituents, even handing out labels identifying them as such – want to talk about single-payer. It's the clear theme from the very start of the night, when a chant of "Single payer! Single payer!" broke out less than ten minutes in, after MacArthur describes the Affordable Care Act as "collapsing."
Derek Reichenbecher, a constituent with a heart condition, is worried what would happen to him if he lost his job and, with it, his insurance – creating a gap in coverage that, under the AHCA, would allow insurance companies to temporarily deny him coverage, charge him enormous premiums or both.
"This is something that's very real. This is my life. So when you talk about health care coverage like this – when you talk about $8 billion to fund a high-risk pool, and you say, 'Don't worry, you already have coverage,'" there are real-world consequences, he says, addressing MacArthur.
"Without health care coverage, I'm dead. I'm dead [or] bankrupt," Reichenbecher says. "This is your amendment, sir. With that amendment, you brought [the AHCA] back from the dead. It's your's; you own it."
The issue Reichenbecher described would be a problem for a "specific, narrow group of people," MacArthur insists, emphasizing that he's worked to get those billions of dollars added to the plan to help fund high-risk pools for people with pre-existing conditions. (That money is doled out over five years, and is considered woefully inadequate to meet the level of need that would be created under the law.)
"These markets are failing," the congressman says over and over again. The insurance companies are losing money and dropping out; this bill, he says, is trying to fix that.
The voters reject that answer on its face. "It shouldn't be a market! My health care shouldn't be market," one yells. "When did we become a society that doesn't care about each other?" another shouts.
And: "I have family in Canada. They get coverage under the under government. They are taken care of, and nobody has any complaints. ... This is all about insurance companies making money at our expense!"
An hour-and-a-half in, 92-year-old Ruth Gage stands up in the back. "We've had this single-payer conversation before," she reminds MacArthur. "You said, 'Would I like some bureaucrat in Washington to make decisions about my health care if we had single payer?' And I said, 'What makes that anything worse than some employee of an insurance company?'"
MacArthur looks at her and says, earnestly, "I think there is a difference. What I have found, in 30 years in the private sector, and now a couple of years in the public sector, is that government bureaucrats can be very dangerous when they have power."
The room erupts into grim gales of laughter. When it finally quiets down, MacArthur can be heard saying, "I don't want a system where there's nobody left to make decisions other than federal bureaucrats – I think that's a terrible mistake for this country. That's my belief."
A little later, a young black man stands up. He doesn't give his name; he just says, "You've been talking a lot about your constituents on the other side of the Pine Barrens and how they affect your policy decisions. When are our ideas, on this side of the Pine Barrens, going to affect your policy decisions? Everybody here is talking about single-payer, and you're still trying to push this other stuff on us, but we are the constituents – if you want to go back [to D.C], if you want another turn, you might want to listen to what these people have to say."
As the night goes on, and MacArthur starts to get a handle of the room, a funny thing happens: He starts trying to sell the high-risk pools his amendment creates by likening them to a single-payer system.
Of the taxpayer-funded high-risk pools, MacArthur says, "it protects you, and it keeps everyone else's premiums affordable. It's not that easy. I understand that another solution [that achieves the same outcome] is single-payer – I get that," he acknowledges, about three hours in. "I think that's not ultimately a good solution for the American people, but I get that it is a solution. I'm trying to deliver a different one."
Geoff Ginter, wearing blue hospital scrubs, isn't buying it. "Health care is not like buying anything else. You cannot expect people to be good 'consumers' of health care," Ginter says. "You're supposed to be vetting doctors and vetting hospitals and knowing what an MRI costs and knowing what a CT scan costs and a cardiac catheterization – how much does that cost? And is the cost different if I have this doctor or this doctor?"
"Health insurance as a for-profit business is immoral," he bellows, as the whole room breaks into applause. "You want to make money off of me. And the reason you [don't want] to go to single-payer is not because you don't believe in it," Ginter adds, straining to be heard. "It's because you know the insurance companies have a powerful lobby and they would decimate you."
He finishes: "I have no value to an insurance company. I can't do anything to their CEO, I can't do anything to their employee. Nothing. I can argue until I'm blue in the face. But a single-payer, run by the government? Yeah, it's got problems, but it's also got elections, and you're going to find that out in 2018."
Now someone tell that to Nancy Pelosi.
Correction: A previous version of this article incorrectly noted that MacArthur worked on health insurance claims. Rather, he investigated "slips and falls, elevator accidents, crimes, and other liabilities" in the New York projects.