On July 30 and 31, the Demo­c­ra­t­ic pres­i­den­tial hope­fuls will face off in the sec­ond round of debates in this elec­tion cycle, and Medicare for All may once again be a theme of the night.

Of the candidates polling in the top five (Biden, Sanders, Warren, Harris, and Buttigieg), Biden has received the most money from health insurance and pharma employees, and Sanders has received the least.

Sup­port for sin­gle-pay­er Medicare for All, a pro­gram that would elim­i­nate pri­vate health insur­ance by expand­ing Medicare to cov­er all Amer­i­cans, has become some­thing of a lit­mus test for the 2020 Democ­rats. Medicare for All is an incred­i­bly pop­u­lar posi­tion across the polit­i­cal spec­trum. Many can­di­dates, how­ev­er, have attempt­ed to stake out a posi­tion some­where between oppos­ing it and whol­ly endors­ing it.

All 20 can­di­dates at the June debates were asked to raise their hands if they sup­port­ed a Medicare for All plan that would elim­i­nate pri­vate health insur­ance. Only four of them did: Bernie Sanders, Eliz­a­beth War­ren, Kamala Har­ris and Bill de Bla­sio. The next day, Har­ris back­tracked, claim­ing to have mis­un­der­stood the question.

The can­di­dates who kept their hands down rushed to explain and stip­u­late. Pete Buttigieg expressed his sup­port for ​“Medicare for All who want it,” a plan which would allow Amer­i­cans to buy into a pro­gram with, as he called it, the ​“fla­vor” of Medicare. Joe Biden echoed Buttigieg’s sup­port for a pub­lic option that would include a ​“Medicare-like” plan. When Beto O’Rourke said that he, too, prefers a pub­lic option to a sin­gle-pay­er pro­gram, de Bla­sio cut in. ​“Why,” he demand­ed, ​“are you defend­ing pri­vate insurance?”

It’s a ques­tion worth ask­ing. Over half of Amer­i­cans sup­port sin­gle-pay­er health­care — one poll even cites a 70% approval rat­ing for Medicare for All. In 2018, a Gallup poll found that health­care is among the most impor­tant issues for vot­ers, a sta­tis­tic that indi­cates wide­spread dis­sat­is­fac­tion with America’s cur­rent health­care sys­tem. With demand for Medicare for All so high, Demo­c­ra­t­ic hope­fuls are loath to stick to the sta­tus quo on health­care. So why are can­di­dates, includ­ing sev­er­al who co-spon­sored Sanders’ Medicare for All bill in the Sen­ate, hes­i­tant to endorse true sin­gle-pay­er health­care? Of course, there may be a fac­tor besides per­son­al con­vic­tion and con­stituent opin­ion: mon­ey. Sev­er­al big-donor indus­tries have a lot to lose from Medicare for All.

The health insur­ance and phar­ma­ceu­ti­cal indus­tries spend large amounts to ensure polit­i­cal influ­ence. Dur­ing the 2016 elec­tion cycle, health­care insur­ance giant Blue Cross Blue Shield shelled out over $25 mil­lion on lob­by­ing and more than $9.6 mil­lion on polit­i­cal con­tri­bu­tions (about $8.2 mil­lion from their PACs and oth­er affil­i­at­ed orga­ni­za­tions, and $1.4 mil­lion from com­pa­ny employ­ees). Pfiz­er, one of the world’s largest phar­ma­ceu­ti­cal com­pa­nies, spent near­ly $9.9 mil­lion on lob­by­ing and $2.9 mil­lion on con­tri­bu­tions ($1.98 mil­lion from PACs and orga­ni­za­tions, and $892K from employ­ees). For both com­pa­nies, the top two recip­i­ents of polit­i­cal con­tri­bu­tions were Hillary Clinton’s pres­i­den­tial cam­paign and House Speak­er Paul Ryan’s con­gres­sion­al reelection.

Both indus­tries have been cen­tral to the fight against Medicare for All. Last sum­mer, health insur­ers, phar­ma­ceu­ti­cal com­pa­nies and pri­vate hos­pi­tals teamed up to cre­ate the Part­ner­ship for America’s Health­care Future (PAHCF), an orga­ni­za­tion ded­i­cat­ed almost entire­ly to killing Medicare for All. Over the past year, mem­bers of PAHCF have lob­bied Con­gress mem­bers and spent thou­sands on online ads to reduce sup­port for Medicare for All among vot­ers and politi­cians. Accord­ing to data from the Cen­ter for Respon­sive Pol­i­tics, the mem­bers of PAHCF spent a total of over $143 mil­lion on lob­by­ing in 2018.

But it appears that even before PAHCF was found­ed, the health insur­ance indus­try was alarmed by the grow­ing momen­tum of Medicare for All. In 2017, Map­Light and Pacif­ic Stan­dard revealed that Sen­a­tors who opposed Sanders’ bill received, on aver­age, dou­ble the amount of mon­ey from the health insur­ance indus­try as did those who sup­port­ed the bill.

Sanders seems to believe that health­care indus­try mon­ey may be influ­enc­ing his 2020 oppo­nents as well. At the end of a speech on July 17th about Medicare For All, he pledged to reject all con­tri­bu­tions over $200 from the phar­ma­ceu­ti­cal and health insur­ance indus­tries, and called on his oppo­nents to do the same. His pledge encom­pass­es dona­tions from PACs, lob­by­ists, and high-rank­ing exec­u­tives. The health­care indus­try, he argued, has been ​“able to con­trol the polit­i­cal process.”

Ear­li­er this month, OpenSe­crets inves­ti­gat­ed which 2020 can­di­dates received the most mon­ey from health insur­ance and phar­ma­ceu­ti­cal com­pa­nies. In These Times also teamed up with researchers from The People’s Lobby’s Fair Elec­tions Task Force, a com­mu­ni­ty orga­ni­za­tion fight­ing for cam­paign finance reform in Chica­go, to gath­er more spe­cif­ic data on indi­vid­ual con­tri­bu­tions. For now, health insur­ance and phar­ma­ceu­ti­cal PACs have steered clear of the 2020 Demo­c­ra­t­ic field, but many of the industry’s high-rank­ing employ­ees have already begun to chip in. Accord­ing to OpenSe­crets’ research, the lead­ing can­di­dates who oppose elim­i­nat­ing pri­vate insur­ance have received larg­er con­tri­bu­tions from health insur­ance and phar­ma­ceu­ti­cal exec­u­tives than the can­di­dates who ful­ly sup­port sin­gle-pay­er healthcare.

OpenSe­crets’ research shows that of the can­di­dates polling in the top five (Biden, Sanders, War­ren, Har­ris, and Buttigieg), Biden has received the most mon­ey from health insur­ance and phar­ma employ­ees, and Sanders has received the least. At $97,453, Joe Biden accept­ed almost three times more mon­ey than Bernie Sanders ($36,728). Pete Buttigieg, a close run­ner-up, received $93,954. Har­ris took home around 1.5 times more mon­ey than Sanders, at $55,359. War­ren accept­ed $43,680, less than 1.2 times more than Sanders.

Though she is not quite a lead­ing can­di­date, polling between 1% and 2%, Amy Klobuchar notably accept­ed $65,304 from health insur­ance and phar­ma­ceu­ti­cal employ­ees, mak­ing her the third-largest recip­i­ent over­all (after Biden and Buttigieg). In These Times found that she received the max­i­mum dona­tion of $2,800 from Kara J. Wal­ter, a Unit­ed­Health exec­u­tive, and $1,000 from David Abel­man, Exec­u­tive VP of Den­taQue­st. Klobuchar is skep­ti­cal of Medicare for All, which in last month’s debate she claimed would kick ​“half of Amer­i­cans off their health insurance.”

Kirsten Gilli­brand is anoth­er favorite of the health­care indus­try — at $39,546, she is the sixth-largest recip­i­ent of mon­ey from health insur­ance and phar­ma employ­ees, above Sanders. Pfiz­er Exec­u­tive Vice Pres­i­dent Sal­ly Sus­man, who donat­ed the max­i­mum $2,800 to her cam­paign accord­ing to In These Times’ research, host­ed a fundrais­er for Gilli­brand ear­li­er this year, which Gilli­brand defend­ed by claim­ing that Sus­man is ​“a friend” and that she ​“sup­ports LGBTQ equal­i­ty.” Per­haps Gillibrand’s rela­tion­ship to the health­care indus­try fac­tored into her choice not to raise her hand in the June debates, and to argue instead that Medicare for All should not touch pri­vate insur­ance com­pa­nies because com­pe­ti­tion will dri­ve them out naturally.

It is no sur­prise that Joe Biden and Pete Buttigieg are the health­care industry’s top picks. Biden recent­ly denounced a poten­tial switch to sin­gle-pay­er health­care as ​“a sin,” and has made absurd claims that Medicare for All would mean exist­ing Medicare ​“goes away as you know it.” Accord­ing to In These Times’ research, his con­tri­bu­tions include $2,800 from Inde­pen­dence Blue Cross CEO Daniel Hil­fer­ty, and $2,800 from Steven Col­lis, CEO of Amerisource­Ber­gen. Buttigieg, mean­while, has man­aged to appeal to both pro­gres­sive Democ­rats and health­care exec­u­tives with his ​“Medicare for All Who Want It” pro­pos­al. In These Times found that his top donors include Wade Rakes, a Cen­tene vice pres­i­dent who donat­ed $4,300, and Joshua Smi­ley, CFO of Eli Lil­ly, who gave $2,800.

Accord­ing to In These Times, Kamala Har­ris’ dona­tions from high-rank­ing exec­u­tives include $2,800 from Danielle C. Gray, Senior Vice Pres­i­dent of Blue Cross NC, and $2,700 from Osi Esue, Mar­ket­ing Direc­tor of Abb­vie Phar­m­a­lyt­ics. Like Buttigieg, she has attempt­ed to play both sides of the debate around sin­gle-pay­er health­care. On Mon­day, a month after walk­ing back her sup­port for elim­i­nat­ing pri­vate insur­ance at the June debates, she final­ly released a health­care pro­pos­al dubi­ous­ly titled ​“My Plan for Medicare for All.” Her plan would take ten years to phase in and would allow pri­vate insur­ance com­pa­nies to com­pete with Medicare. ​“You can’t call this Medicare for All,” said Sanders’ cam­paign man­ag­er in a state­ment about Har­ris’ plan. Along with Har­ris’ new plan came a state­ment that her cam­paign does not take any mon­ey from phar­ma­ceu­ti­cal exec­u­tives, but she has not yet returned most of the mon­ey she received from them.

For his part, before Bernie Sanders announced his pledge to reject health insur­ance and phar­ma dona­tions over $200, he accept­ed dona­tions that would have bro­ken it. For instance, In These Times found that he took at least $920 from Lynn McRoy, a med­ical direc­tor at Pfiz­er who may or may not count as a ​“high-rank­ing exec­u­tive.” OpenSe­crets also report­ed that he took home $2,000 from the CEO of Iron­wood Phar­ma­ceu­ti­cals. Bernie’s cam­paign has announced that it will return all pre­vi­ous­ly accept­ed dona­tions that vio­late the new pledge.

Like Sanders, War­ren received a rel­a­tive­ly small amount of mon­ey from the health­care indus­try. In These Times found few high-rank­ing exec­u­tives on her list of con­trib­u­tors, though she did accept some sig­nif­i­cant con­tri­bu­tions, such as $1,010 from Robert Cud­di­hy, Amgen’s Vice Pres­i­dent of U.S. Med­ical Affairs. Before the June debate, she was crit­i­cized for her silence on Medicare for All, but she has since come out in full sup­port of sin­gle-pay­er health­care, includ­ing for undoc­u­ment­ed immigrants.

While all but two of the lead­ing 2020 Democ­rats equiv­o­cate on sin­gle-pay­er health­care, orga­niz­ers around the coun­try con­tin­ue to fight for Medicare for All and for the cam­paign finance reform that may be nec­es­sary to make pro­gres­sive poli­cies like sin­gle-pay­er a real­i­ty. For these orga­niz­ers, con­tri­bu­tions from the health insur­ance and phar­ma­ceu­ti­cal indus­tries are more than just numbers.

Mor­gan Oliv­er, an orga­niz­er from the Fair Elec­tions Task Force, believes that with­out big mon­ey in pol­i­tics, a uni­ver­sal health­care sys­tem would be far more polit­i­cal­ly pos­si­ble. ​“People’s con­stituents want that,” she added. ​“We see how many peo­ple have strug­gled with the health insur­ance indus­try in many dif­fer­ent ways, even peo­ple in very con­ser­v­a­tive com­mu­ni­ties.” This strug­gle is per­son­al for Oliv­er as well — she told In These Times that even with pri­vate insur­ance, she has strug­gled to afford a med­ica­tion that she needs because it cost near­ly $4,000.

Oliv­er is work­ing to pass a Fair Elec­tions Ordi­nance in Chica­go that would cre­ate a donor match pro­gram for small indi­vid­ual con­tri­bu­tions. She believes that fight­ing for cam­paign finance reform local­ly is a cru­cial step to win­ning it nation­al­ly. She envi­sions a fed­er­al pub­lic cam­paign financ­ing law that would restrict big mon­ey in pol­i­tics while boost­ing the pow­er of small dona­tions through vouch­ers or donor matching.

Sheilah Gar­land, a polit­i­cal orga­niz­er with Nation­al Nurs­es Unit­ed, which has long fought for Med­ical for All and endorsed Sanders in 2016, says that nurs­es around the coun­try vis­cer­al­ly under­stand the neces­si­ty of divorc­ing health­care from prof­it. She cit­ed the Part­ner­ship for America’s Health­care Future as a major obsta­cle in the union’s fight for sin­gle-pay­er health­care, along­side gen­er­al lob­by­ing and con­tri­bu­tions from health insur­ers and Big Pharma.

Gar­land says her expe­ri­ence work­ing with nurs­es has demon­strat­ed the impor­tance of elim­i­nat­ing pri­vate insur­ance through Medicare for All. Almost every nurse in the coun­try, she says, has watched a patient strug­gle to access a life-sav­ing treat­ment that isn’t cov­ered by their insur­ance company’s policy.

“When you’ve spent time with [a patient],” Gar­land said, ​“you know their sto­ry. You see them, you see their fam­i­ly, you see their strug­gle to regain their health … and to see all of that lit­er­al­ly washed away because of some sort of pol­i­cy … it’s absolute­ly devastating.”

Nathan Whit­more, a researcher from The People’s Lobby’s Fair Elec­tions Task Force, con­tributed research to this article.