A Cloward-Piven Strategy for Single Payer?


With yesterday’s passage in the House of the Obama administration’s health care reform bill, it would seem at first glance that the movement for national, single-payer health insurance has been seriously derailed. After all, if all of the hype and adulation surrounding the bill’s passage is to be believed, the fight for universal health care is basically over, except for necessary technical tweaks that will “fix” and “improve” the bill in the coming years.

However, there are many serious flaws in the bill that will put single payer back on the political agenda sooner than we may think. The indispensable and indefatigable folks at Physicians for a National Health Program (PNHP) cataloged many of them in a press release earlier today, but they only briefly touch on an issue that I think could potentially be a central aspect of single-payer strategy in the coming years: Medicaid and the fiscal crisis of the states.

Under the plan that Congress will pass, about half of the roughly 30 million people that would gain access to health insurance coverage would be placed in Medicaid. Medicaid is funded jointly by the federal government and the states, but the combination of dwindling tax receipts and surging enrollment – an estimated 3.3 million people joined the program in the last year alone – has severely impaired the states’ ability to meet their Medicaid obligations. This has forced many states to cut Medicaid reimbursements to doctors, resulting in drastic hardships for many Medicaid recipients. And last week, Arizona completely eliminated funding for the state’s Children’s Health Insurance Program, leaving 47,000 children without health insurance coverage. Besides, even before the recession, Medicaid was a badly underfunded and often inadequate program, even though five to seven million people that are Medicaid eligible are not even currently enrolled in the program. It’s true that under the plan that will be passed by Congress, the federal government will cover the cost of Medicaid expansion until 2016, but after that the cost burden will begin to shift back to the states. Since state budgets are not expected to return to health any time in the foreseeable future, Medicaid expansion could potentially break the budgets of many states around the country.

So what does this all have to do with formulating a winning strategy for the single-payer health care movement? To begin to answer this question, we need to look back at an old strategic proposal that I think has acquired a new relevance in the political terrain created by the passage of the Obama administration’s health care reform bill.

In 1966, scholar-activists Richard Cloward and Frances Fox Piven (a long-standing DSA member) wrote an article for The Nation called “The Weight of the Poor: A Strategy To End Poverty.” In the mid-sixties, Cloward and Piven found that only about half of the families eligible for Aid to Families with Dependent Children (what welfare used to be called), were actually enrolled in the program. Recognizing the political opportunities this gap between welfare law and practice presented, they formulated an analysis that became known as the “Cloward-Piven strategy.” As they explained in their book Poor People’s Movements, the strategy had two main components:

If hundreds of thousands of families could be induced to demand relief, we thought that two gains might result. First, if large numbers of people succeeded in getting on the rolls, much of the worst of America’s poverty would be eliminated. Second…we thought it likely that a huge increase in the relief rolls would set off fiscal and political crises in the cities, the reverberations of which might lead national political leaders to federalize the relief system and establish a national minimum income standard. It was a strategy designed to obtain immediate economic aid for the poor, coupled with the possibility of obtaining a longer-term national income standard.

The Cloward-Piven strategy to win a guaranteed minimum income for all Americans failed for a number of historically specific reasons, and a discussion of why this happened is beyond the scope of this piece. But the parallel between the premises of the original Cloward-Piven strategy and the situation we find ourselves in today in the fight for single payer presents itself fairly clearly. As efforts to win single payer through traditional organizing techniques and engagement with the established political system fail to bear much fruit, the crisis provoking strategy proposed by Cloward and Piven may be our best way forward.

So here’s what I would propose as the next step in single payer strategy: explode the Medicaid rolls. Single payer activists should organize in their communities to sign up as many eligible people as possible for Medicaid – if the administration wants to expand Medicaid coverage, then let’s give it to them. Many people would get the health coverage they need in the short term. In the longer term, the system would probably not be able to support all of them when the financial burden shifts back to the states. Popular pressure could then be mobilized to force drastic federal intervention to deal with the ensuing crisis, possibly including the implementation of single payer.

Of course, there are some serious potential disadvantages to this strategy. For it to be successful, the balance of political forces at play when the crisis is provoked would have to be favorable to the left and to poor and working people so that it is not settled on right-wing terms. Needless to say, the prospects for creating such a balance doesn’t seem to be terribly favorable right now. I think, however, that engaging in unorthodox and frankly risky strategies like the one proposed here can help to create the conditions for its own success. In any case, if meaningful progress toward the establishment of a national single payer health care system is to be made, it’s clear that we need a new strategy. Challenging the administration’s health care reform on its own terms could be a very good place to start.

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  1. Great idea. Tell me where to sign up.

    BTW, I’d love to hear your analysis of why Piven Cloward failed if you have the time and energy to write another piece.

  2. This is clever, and an attractive proposal. And just the the kind of “building toward the crisis” that I think we need to be working on. Of course, to have a more than symbolic impact it would have to be done on a mass scale, so it would take much more than just single payer activists. So the question is then, who has the organizational capacity to do something like this who would actually be interested in it?

    The other problem is that the Obama administration and congress have positioned themselves to flip into budget-balancing austerity mode as soon as they can plausibly claim an economic recovery is underway, so we’d likely hit a brick wall with them. But that’s no reason to hold back, since breaking through the fiscal consensus in Washington is a prerequisite for accomplishing basically anything. And we’ve already seen how much incentive congress has to push for federalizing Medicaid–that’s what Ben Nelson’s “cornhusker compromise” was about, after all. The endgame here is probably just federalized Medicaid rather than full single payer for everybody, but it’s still worth a shot. And getting rid of the uneven application of Medicaid across the states would be worth it by itself.

    • Also, check out this from the American Prospect:


      Apparently the paranoid right has been freaking out about the Piven-Cloward strategy already.

      • I realized that too as I did a little background reading on the Cloward-Piven strategy. Actually, if you look at the screenshot I used as the photo accompaniment for this post, you’ll see a little GB logo in the lower right hand corner – apparently Beck did a big segment about them on his show somewhat recently. It’s really weird that there’s probably now more right wingers that know about Cloward and Piven than left social movement activists.

  3. This is a really interesting idea. The biggest (and simplest) problem I can see with this approach is that it would require massive organization and planning and an amount of strategic movement that the left just doesn’t have right now in order to make this plan really work.

    • Sure, I agree right now that the left and the single payer movement don’t have the capacity right now to build an effective campaign like this. But the Medicaid expansion doesn’t go into effect until four years from now. We have some time to build toward something like this, and who knows what the political landscape will look like then?

  4. I love this idea: the Bank-Run on Health Care.

    Not only does it put demand on the public provision of health care, but cuts into the revenue of private health insurance providers.

    Also, it is risky (Find an amusing article on risk taking here: http://whatsthematterwithkansas.com/2010/03/thomas-frank-and-david-frum-agree-tea-parties-made-for-tv/ ).

    I think there may be a shift in allies here though. Our greatest ally is the everyday citizen, both the one who is eligible and who knows an eligible party, and as an “often inadequate” system is further burdened, the result is not just symbolic, but will have human consequences. Some of our comrades with PNHP too may fall away under the threat of economic hardship and other concerns.

    Can popular support and pressure keep up with the demand on the system, and if so, how will this effect the symbolic leverage for single-payer that is being strived for?

  5. There’s also the option for independent union forming: http://amleft.blogspot.com/

  6. Oh no, our plan to destroy capitalism has been exposed: http://keywiki.org/blog/?p=35

    • Maria, of course the plan has been exposed. It was exposed in the murder of millions by communist/marxist nations. It was exposed in the starvation and serfdom of formerly free people in those same nations.

      Sadly, our “masses” were so uninformed that we elected a progressive in Woodrow Wilson, who was a racist and even gave export to the solutions in how to gain control of the people. Why even after McCarthy exposed communist and their spies in the US Government, we were so gullible as to issue an affirmative action to communists in immigration so as to not “hurt anyone’s feelings”. I certainly don’t think the SD’s worry about that, eh?

      I do like the following reply by Neb to Chris’s antic plans;

      “Neb Zeltrex says:
      March 27, 2010 at 4:32 am

      Not to sound like a simple e-heckler, but this is among the stupidest, most reckless, least probable to happen, least probable to succeed, irrelevant, comical, laughable, irresponsible, and childish commentaries on the national health policy debate I’ve ever read.”

      One thing it looks like is missing in all these wondrous ideas to “take down the government” is, where in the you know what will you get money after that.? Please explain that without saying how many banks you will empty on your way to “workers of the world unite” wonderland. Or, that “we will not practice the method of capitalistic greed by desiring riches” or something on that order.

      This nation voted for hope, and they were given serfdom. The SD movement already had Obama in their puppet strings, using worn-out ’60s bombers to surround him with their dribble.

      Those of us who really know what hope is, are not at all worried about your criminal thoughts on how to carry out a stretched version of sedition, without too many people getting upset all at once.

      Good luck to you, after you enslave the “people” you’ll only have the Islamists to worry about. Take you nose out of your Cloward and Piven banners and look at Europe and how the Islamists are gaining ground on even the progressives. Please read their Koran to find out what practices they abhor so you will change your way of living in what they deem as “despicable to Allah”.

      You will see then what you did not win by enslaving the masses.

  7. Holy shit! Chris is David Tennant!

  8. I just ran across this piece, and it’s now March 2013. Fiscal crises are occurring in multiple cities and states, and to my knowledge, in every single place — including the federal gov’t — the fiscal crises are being used to dismantle gov’t programs. And I suspect that right-wing propaganda in regard to this particular strategy has (at the very least) served to increase to perception that people receiving gov’t aid don’t really need it (and that is one perception ought to be fighting against, not aiding). Anyway, I wonder if the anyone here — Chris Maisano and others — still endorses this strategy? I also noted that, in this post, there’s a hint of a view that things couldn’t get worse, so why not try something risky… But the fact is, things can *always* get worse.


  1. A Cloward-Piven Strategy for Single Payer? « Bear Market News
  2. Deliberately Bankrupt Medicaid to bring about Socialized Health Care ? « KeyWiki Blog
  3. Attack the System » Blog Archive » Updated News Digest March 27-28, 2010
  4. A Cloward-Piven Strategy for Single-Payer? « New York City Democratic Socialists of America
  5. Deliberately Bankrupt Medicaid to bring about Socialized Health Care? « Romanticpoet's Weblog
  6. A Cloward-Piven Strategy for Single Payer? | Tech News, Reviews, Business, Health News and More

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