Hell hath no fury like a coalition of health care lobbyists scorned.

The health care industry spends hundreds of millions lobbying each year. The post-Citizens United political ad frenzy has been extremely profitable for news broadcasters for nearly a decade. So, one can only imagine how much money the major power brokers of the health industry are prepared to spend to stop single-payer from becoming a consensus position among Democrats.

The U.S. health system works, in that it is doing what it was built to do: create profit for wealthy shareholders. The system works great for wealthy executives and the ownership class but is entirely dysfunctional for the majority of people: It bankrupts and kills the poor while widening profit margins for the wealthy. It is a national embarrassment and a brazen moral abdication of one of the most basic functions a government can serve.

Most Americans in supporting Medicare for All seem to either know or strongly suspect this to be true. But the industry’s privileged status and hefty profits nevertheless allow it to shape the national debate and politicians in Washington. Our electoral system allows the most powerful industries so much influence that invariably, the people shaping the debate are doing so on behalf of commercial interests — not for patients, taxpayers or citizens.

This election cycle the hub of the single-payer opposition has come mostly in the form of the Partnership for America’s Health Care Future (PAHCF), a coalition of nearly every major powerful lobby in the private health industry. Among the powerful entities in the coalition are the largest drug, insurance and hospital lobbies in the country, among many others (all large spending lobbyists in their own right). The coalition has one goal: to prevent support for single-payer from emerging into a consensus position for Democrats, despite being so popular with Democratic voters.

The battle is accelerating quickly as the 2020 presidential campaign has been filled with Medicare for All discussions (and just as many distortions) in the press. Recently, Bernie Sanders released his Senate version of Medicare for All (S.R.1129), now with 14 co-sponsors. The Partnership wasted no time in responding to Sanders, calling the bill one that “destroys our system.” PAHCF failed to mention that countries with single-payer systems spend about half of what the U.S. pays, have in most cases better health outcomes, and provide coverage to every citizen.

The PAHCF’s power plays are being made at the regional level as well, not just in the media circus of the presidential primary. In Massachusetts, for instance, Rep. Lori Trahan (D-Massachusetts) recently co-sponsored single-payer legislation. Interestingly, Trahan was previously courted by the coalition to be a surrogate of its views. Leaked slides revealed strategic plans from the group, such as “earned media” and visits to Congress. Earned media is positive press, essentially, as opposed to a paid ad. The slides highlighted several favorable, “earned,” articles. They also gave briefings with several members of Congress and their staffs. PAHCF provided talking points, data and other arguments against Medicare for All.

They provided a note about their courting of Trahan in the documents. She expressed concerns about “single-payer rhetoric” but otherwise “did not discuss the issue.” Trahan’s campaign site has a health care section that very much toes the establishment line. There is no reference to Medicare for All or single-payer — advocated by DCCC and Third Way that cycle — but rather her “plans to build on” the success of the Affordable Care Act and “make sure no American is left uninsured.”

Screenshot from the Intercept

This lack of support for Medicare for All may have been what prompted the Partnership’s decision to approach her. In the face of this pressure Rep. Trahan went another way. Rather than become a surrogate for the private health industry in fighting the policy, she became the 107th co-sponsor of the House version of Medicare for All in the current Congress. (There are now 108 , as Elijah Cummings has since co-sponsored as well.)

“Big pharma, health insurers and for-profit hospitals are now using our health care premiums to publicly attack legislators who defend our right to health care.”

Trahan’s decision, however, might cost her. Now, the private health interests whose advances she resisted are on the warpath. Less than two weeks after Trahan co-sponsored the legislation on March 27, she became the target of the first individual attack ad from the Partnership for America’s Health Care Future on April 8, according to Facebook advertising data. As of April 11, there were 1,800 ads total on Facebook paid for by the PAHCF, according to Facebook’s ad library. The life span of the ads is short by design so most of the ads are “inactive.” But they all reflect the recent use of social media by the organization. Other ads include general messages such as videos telling voters to “stop Medicare for All”.

The tactic sends a message to other Democrats that there are consequences for spurning some of the most powerful interests in the country, some of which see this as an existential battle to justify their existence. This large group went after Trahan by running attack ads in her district.

Dan Diamond tweeting for Politico. Facebook Ad Library, accessed April 14, 2019.

“Big pharma, health insurers and for-profit hospitals are now using our health care premiums to publicly attack legislators who defend our right to health care,” said Benjamin Day, director of Healthcare-NOW, a pro-single-payer organization. “It’s an unbelievable testament to where health care politics are at these days.”

Advocates have called this tactic the “lover spurned” situation and are starting to prepare counterstrategies.

“We face a formidable opponent with a lot of money and a lot of success at keeping the truth about Medicare for All from the public,” said Adam Gaffney, president of Physicians for a National Health Program. “We have to be prepared, we have to work, and we have to just tell the truth about the benefits of this program in solving our terrible crises.”

The “Coalition of the Billing” Weaponizes ACA

The PAHCF’s existence first gained widespread notice when The Hill reported on it not long after its founding in 2017. The group started with a minimal website, no list of staff, one statement from its launch and almost nothing else. What the coalition’s website said about health care was never a direct attack on single-payer or Medicare for All in the beginning. In fact, PAHCF almost never used those terms; it simply pushed “bipartisan improvements” to the Affordable Care Act (ACA) and Medicaid expansion — the industry-friendly policies that make up the status quo. This included a commitment to following the “Health Statement of Common Understanding” from the Bipartisan Policy Center — a pledge to work in a bipartisan way to offer middle-ground health care policies — as its only major piece of literature for some time. The Health Statement of Common Understanding is signed by prominent Democrats, such as former Senate Minority Leader Tom Daschle and Andy Slavitt, who worked for the Obama Administration. There are also people from the right, such as former Senate Majority Leader Bill Frist and Jim Capretta from the right-wing, American Enterprise Institute.

The industry’s interest in maintaining the status quo is nothing new, of course. America’s Health Insurance Plans (AHIP), formerly known as Health Insurance Plans of America, pummeled President Bill Clinton’s health care bill with a barrage of attack ads to stop the 1993 Clinton reform. AHIP is currently in the PAHCF. Over the years, however, Democrats became closer with the health industry. By 2010, when the ACA was passed, President Obama tried to cooperate with — rather than challenge — the industry. The results have been mixed. It enabled 20 million Americans to get insurance. Still, it leaves many uninsured and facing medical debt that leaves patients liable for financial ruin.

PAHCF wants to create the impression that single-payer would destroy the ACA.

The private health industry does not always go with a scorched-earth attack via a television commercial. In fact, a quick read at the PAHCF website, which largely advocates for the expansion of the ACA, does not look very different from a Democratic National Committee issue page on health care. Careful language demanding “private and public” access to care and expanding Medicaid reads like standard Democratic orthodoxy — think the Clinton campaign or the Center for American Progress.

Unsurprisingly, the coalition and its members have maintained a solid and mostly transactional relationship with the New Democratic Coalition, the Democratic Congressional Caucus Committee allied think tanks like the Center for American Progress, and the bulk of the party’s leadership in Congress.

In fact, one of the most worrying trends is that the positions taken by the Democratic Party and groups like PAHCF are nearly identical: protect and expand the ACA, universal “access to affordable … private care,” strengthen the mandate to buy health insurance, and expand Medicaid — all of which generate great profits for the industry. Among the key tactics PAHCF wants to use, the leaked documents say, is to create the impression that single-payer would destroy the ACA.

Arguably, the only difference between the industry and the party is that some establishment Democrats support a so-called Medicare Buy-In plan, which would allow some new people, depending on age or location, to buy into Medicaid or Medicare. This is often called a public option as well. Much of the health industry has spoken out against these policies. However, a Medicare buy-in or public option plan would largely preserve the status quo. PAHCF would probably view a weak public option to be a big victory at this point — especially since private companies could end up administering it anyway.

Medicaid and Medicare contracts are virtually always administered by a private third-party provider that is paid billions to service Medicare and Medicaid plans. The managed care market, as it is called, is the biggest growth area in the world of insurance. This is why both advocates and stockholders were equally jubilant after the 2018 election, in which three states expanded Medicaid.

“The press and people in the industry have spent decades telling Americans to be afraid of [a Medicare for All] and yet there is more support for it than ever before. We know our opponent is considerable,” Gaffney said. “It has been 50 years. The time for incrementalism is gone. We need to get this done.”

It is this kind of passion and optimism that has the industry so worried.

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