Healthcare in the United States, unlike in other rich nations, is sadly and dangerously tied to the business cycle—because most workers receive insurance coverage through their employers, job losses can be doubly devastating. That’s why it’s important to think about an eventual next recession as an opportunity to redefine the federal government role in the economy, and in the healthcare sector in particular.

It’s remarkable how far the healthcare debate has come in just a few short years and it’s not accidental. The last time Americans saw this level of public dialogue about changing the healthcare system was back in 2008, when Democratic candidates all vowed to reform the system and cover the growing masses of uninsured leading up to the historic election of President Barack Obama in 2008, as well as political trifecta for Democrats in Washington.

For over a year, advocates labored to pass the new law that would eventually expand coverage to 25 million more people, bringing the number of uninsured Americans to a historic low and ushering in the largest expansion of government healthcare since the passage of Medicare and Medicaid in 1965. Yet, despite its accomplishments and the popularity of individual provisions like pre-existing conditions protections and Medicaid expansion, the Affordable Care Act never reached consistent majority support from voters until President Donald Trump tried to repeal it in 2016.

The fight to save the ACA validated what healtchare advocates have known for years: when it comes to healthcare, most voters don’t like big change—especially changes that would take away healthcare or give the insurance industry more power to jack up prices, deny benefits and discriminate against the sickest people.

Trump’s relentless attacks on the Affordable Care Act and Medicaid turned healthcare into a key election issue in 2018, as well as a driver of Democratic success in regaining a majority in the House of Representatives. The tremendous attention to healthcare in the first two years of the Trump era opened a window into a much larger healthcare debate that serves as a proxy for an alternative vision of the economy and our democracy—one that challenges trickle-down economics and the supremacy of free market ideology.

The emergence of “Medicare for All” or universal healthcare as a mainstream issue in the coming elections is a key manifestation of this shift. While the Medicare for All debate is still mainly confined to the Beltway, but the coming Presidential elections could change all that as Democrats vie to offer up the boldest solutions on the campaign trail, Republicans fight among themselves over replacements for the ACA, and health industry players do their best to preempt any reform that might force a change in their business model that limits profits.

While progressives are entangled in a debate about the false dichotomy between “incremental” reforms and “transformative” change, polls suggest that voters’ concerns about healtchare are less arcane: they want lower costs, preservation of key protections that stop insurers from charging people with pre-existing conditions more for coverage, and they want to preserve Medicaid and Medicare–our largest government healthcare programs.

This last point is crucial, since it’s also a point of fundamental consensus among Democrats and the greatest area of contrast with Republicans. At this moment when there is divided control of Washington, Democrats don’t need complete agreement about the precise degree to which healtchare should be government-run. A debate that posits different versions of government intervention as alternatives to the existing market system is itself helpful to keeping healtchare on the menu between now and 2021 when unity among Democrats becomes more essential to passing policy. That debate on the role of government is also critical on many other issues that are top of mind for Americans.

Keeping a chorus on healthcare and taxes between now and 2020

If progressives are smart, they will capitalize on the growing buzz about healthcare coming from all quarters that is likely to keep it a top issue in the 2020 election and beyond. It’s an issue that gives progressives leverage and creates tremendous liability for the opposition, making it a helpful lever in any upcoming debate about future recession or a robust stimulus package that could address the downturn.

Every politician is talking about healthcare, but it’s important to also recognize there’s a subtext in the messages that point to bigger themes around spending and the role of government, no matter what words the politicians use:

• President Trump can’t shut up about healthcare, touting his new efforts to lower the cost of prescriptions and pass an ACA replacement that will give Americans “great healtchare” while continuing efforts to dismantle the ACA administratively and in the courts. He consistently proposes cuts to Medicaid and Medicare, popular government programs that he vowed to protect while promising seniors, his most valued constituency, lower Rx costs.

• Republicans in Congress have discovered that protections for pre-existing conditions and Medicaid are incredibly popular and now are alleging support for retaining them while throwing out the rest of the ACA. Reeling from the political consequences of their failed ACA repeal efforts and Medicaid expansion ballot measures in conservatives states, the GOP is now looking to convince voters that Republicans will take action to make healthcare better by protecting pre-existing condition provisions and taking on pharmaceutical giants to lower drug costs after voting to giving those same firms a massive tax break partially paid for by cuts to healthcare.

• Democratic Speaker Nancy Pelosi, recognizing a winner when she sees one, has already started her effort to make healtchare the top issue of 2020 with a new package of healtchare reforms “for the people,” that actually would protect the ACA, make healthcare more affordable and even expand coverage for people who currently have no access. This is an opportunity to keep the healtchare conversation moving forward in a divided Congress that is unlikely to pass any bills and to keep points to tax breaks for the rich and corporations as a way to pay for improvements in healthcare.

• Progressive Democrats led by Representative Pramila Jayapal and Senator Bernie Sanders have launched their Medicare for All bills in an effort to make single-payer a litmus test for Democratic candidates in the coming 2020 elections. Aside from their bills, there’s a wide array of proposals to expand coverage through buy-ins and public option alternatives that could keep healthcare on the political menu for quite some time. All include an expanded role for government and measures to reduce profit while protecting patients.

All the talk about healthcare doesn’t exist in a vacuum: it’s part of a growing chorus of progressive notes that also includes taxes and spending. Though it may feel counterintuitive to some, a lot more talk about taxes is good for healthcare as well as every other issue progressives work on given that everything we want requires revenue and investment.

Running from the tax issue over the years has put Democrats further behind on an investment agenda. It is impossible to have any meaningful conversation about expanding or improving healthcare without talking about taxes because the two issues are inextricably linked—no matter how much pollsters and message gurus may try to segregate them in the interest of avoiding public anxiety about spending.

Health Care For America Now has long recognized this link: without taxing the rich and health industry, we would not have the ACA. In 2017, HCAN was among the first groups to jump into the fight against Trump’s proposed tax law, playing a major role in mobilizing the public against the proposal and leveraging the capacity of healthcare advocates and organizers to fight against the bill as a way to protect healthcare.

A key contributor to our success was the capacity to trumpet a “connect the dots” narrative that helped voters understand the relationship between tax breaks for the rich and corporations and cuts to healthcare they count on. Polling from Americans for Tax Fairness showed that talking about taxes and healthcare together in a way that connects the dots for voters helped increase support for progressives positions while at the same time animating voters against Trump’s tax giveaway to the rich.

The legislation narrowly passed, giving nearly $2 trillion in tax breaks to the rich and corporations while making cuts and changes to the Affordable Care Act that will result in higher premiums and losses of healtchare coverage. Despite legislative success, the Republicans lost the political narrative. Persistent and ongoing efforts to expose the real impact of the Trump tax law have made it one of the most unpopular measures ever passed and transformed Trump’s signature achievement into a moot political victory.

The 2017 tax law debate brought support to higher levels in the public than we’ve seen in a decade while helping construct a larger economic story about the choices politicians make to rig the economy in favor of the rich and corporations and against the rest of us that resonates with voters. This narrative framework offers opportunity in our future efforts to advance our political and policy debates.

Winning politics is not the same as winning policy

Winning a political debate is an important precedent to advancing policy, but when it comes to most issues, politics won’t get you all the way there. High public support for an issue or a policy or anger against a target is not enough to pass any bill in Congress given well-resourced opposition and the energy it takes to keep our side unified. Progressive should know that by now, but some still seem caught up in a narrow mythology that electing the right president or the right Congress will solve our programs obscuring the reality that organizing voters into a constituency—not just electing candidates—that is the real long-term strategy for advancing a progressive agenda.

In 2008, nearly every Democrat including President Obama ran on healtchare reform, positioning healtchare as a top issue for the new Congress and Administration. But a political mandate coming out of the election was insufficient to actually pass the policy we wanted even with Democratic control of both chambers of Congress and a Democratic president. Passing the ACA required tremendous advocacy and organizing beyond the Beltway in order to hold Democrats accountable for passing the policy they promised as candidates—and progressives still didn’t have enough power to win all they wanted in the bill.

Moreover, even after passage of the ACA, grassroots organizations have had to mobilize time and again to enact the law, defend it from every imaginable attack and promote it continuously to counteract the relentless maligning from the right—just as we have done with Medicaid, Medicare, Social Security, public education and every other major public investment.

Both Democrats and Republicans have learned the hard way that winning elections is not enough to win policy reform.

Republican control of the Presidency and both chambers of Congress after the 2016 elections ultimately didn’t automatically secure Trump and the GOP what they named as their number one goal in 2017: repeal of the ACA. The Republicans had control of both chambers of Congress, but not enough consensus on a viable alternative to the ACA to force repeal and replace. Key vulnerable Members faced too much political risk by supporting a repeal that would have stripped massive Medicaid funding from their state and key industry players. After all, taking away constituents’ healthcare is not a popular thing for any politician to do.

There’s a cautionary tale here about not underestimating what it takes to move politicians in either party to pass new, ambitious measures that may require political risk-taking and leveraging influence from outside stakeholders.. As Democrats learned in 2010 when many who supported the ACA in Congress were replaced by Republicans, risk-taking falls hardest on lawmakers who are not in solidly blue areas on the coasts. The Republicans just learned that same lesson after getting trounced in 2018 over repeal of the ACA.

That political reality doesn’t mean that progressives can never pass anything ambitious, but it does mean that doing so requires tremendous effort as well as building significant consensus across the political spectrum, even if it’s to push one party. Neither Democrats or Republicans are monolithic.

Advancing bold change, including any big investment, requires the engagement of constituents at fairly large scale. To influence political calculation that is at the heart of most policy decisions, politicians must see visible organizing beyond the beltway—in their home districts—that communicates the political consequences or advantages of their position. That’s true whether we are trying to herd Democrats in a unified direction toward ambitious policy or trying to stop a bad compromise policy or a full on attack on programs from Republicans. There must be a sophisticated “inside” game in Congress that operates in deliberate relationship to a robust “outside” game in the states in order to drive politics and policy at the same time. Passage of the ACA in 2009-2010 is a good example, but Republicans’ 2017 efforts to repeal the ACA provides even more evidence.

In December 2016 when Republicans swept control of Congress and the Presidency, Beltway advocacy groups urged a surgical legislative effort in a half-dozen states with key Senate GOP targets rather than a large-scale political response.

HCAN disagreed, recognizing that healtchare is always a political fight requiring mobilization, narrative and contrast particularly in salient swing districts that were sure to be consequential in the coming 2018 election. A large-scale on the ground fight-back was needed to define the political context that would make Republicans think twice (or three times) about voting to take away their constituents’ healtchare. Without massive public outcry and mobilization that added up to a unified, powerful narrative and in-district advocacy across many states, progressives would not have stopped repeal in the House and would not have tainted the vote sufficiently in the Senate. HCAN ran a program that enlisted partners across 37 states and many national allies to do just this.

It was exactly the same kind of campaign that we organized to pass the ACA in the first place and that’s why we succeeded. The engagement and meaningful participation of millions of people outside of Washington, DC is required whether you want to advance a policy or defend one. Without organizing in states that engaged both wholesale and (organizations/institutions) and retail audiences, progressive efforts fail. Moreover, without an analysis of which constituents and voters matter most to targets—we’ll also fail.

Winning requires more than mobilization of people who are solidly with us on the politics and the policy. It also requires expansion and persuasion—that is, organizing those who may not fully agree but can be persuaded or moved to support our position. These are the voters who are most often important to building a consensus in Congress and to pushing lawmakers over the risk hump.

Winning new policy also requires more than the “resistance” tactics we’ve seen so effectively neutralize opponents in the Trump era. These efforts are primarily reactive and political and will continue to play a helpful role, but as every organizer knows there’s more to building power than agitating or demonstrating anger.

We also have to animate hope and raise expectations about how life could be different so that people are willing to advocate for new alternatives beyond just reacting to what options already exist. Those alternatives must be articulated in a way that regular people can understand, repeat and internalize. Anger, hope and a simple plan for concrete action are the basic ingredients for big change on any issue. That concrete action must speak to our most fundamental beliefs about democracy in order to animate the agency of regular people in making change beyond electing any candidate to a particular office.

Real people must be the heroes to win policy change

Leading with the personal impact on real people has consistently been the key ingredient to protecting healthcare and advancing reforms. Their participation is required to best capitalize on any next big opportunity for stimulus and investment.

The fight to pass and protect the Affordable Care Act, Medicare and Medicaid provides helpful lessons for how to build enough visible demand for comprehensive policy change to influence lawmakers toward taking on large, costly reform—like a major stimulus package—despite limited bravery. While no one follows the specific debate Democrats are having in Washington, DC about specific policy proposals—voters will want to know how the policy affects them personally—that’s more important to most voters than macroeconomic impact on the nation, political ideology or specific candidates.

That’s why we need more than candidates and politics: we also need a narrative about values that regular people can see themselves reflected in and that feels relevant to their lives. We also need a strategy that connects short- and long-term victories. In moments when we can’t win everything, we must at least win some things that real people can actually discern in their lives. It’s not an accident that support for the ACA increased significantly—even in conservative states like Idaho, Nebraska and Montana—after the law was implemented and millions of people have had a direct experience of coverage and services.

That’s true even in the case of popular issues like healthcare because support for taglines doesn’t always translate into support for policy as we’re finding out with Medicare for All. The uncertainty about specific details, the lack of confidence in government and fear of change can make the battle to advance policy reforms–even those that prospectively improve lives–much more uphill, requiring more power to get over the finish line. The good news is that we have crossed that finish line before and have a road map to get there again.