"There was a centrifugal force taking place," Kahn recalled. "Just as the Republican Party was pushing further and further to the right, that centrifugal force was pushing the Democratic Party further and further to the left."

That newfound liberal momentum needed a counterweight, he added, something that could forcefully remind Democrats that their alternative to Republican repeal and replace -- and the best pathway toward universal health coverage -- was staring them right in the face. Better yet, it was already the law of the land. "You've achieved the framework you wanted to achieve as a party," Kahn said of Obamacare. "Now let's just make it work."

‘Everybody saw the threat’

Kahn's broad coalition would be a rare collaboration in Washington lobbying's ultracompetitive culture, and it took some months to coax his chief rivals on board. There were negotiations over who would control the group and set its principles, coalition members present at the time said, and importantly, how it would remain isolated from the groups' individual policy agendas.

"One of the ground rules we agreed upon early on," said David Merritt, a participant on behalf of insurer lobby AHIP, "was you're not going to bring your baggage to this coalition."

But the hypothesis at the group's core — that without organized pushback, Medicare for All represented a real and imminent threat to survival — was never in dispute.

Under Sanders' single-payer plan, private health insurance — a $670 billion business — would cease to exist. Hospitals, no longer able to strong arm private insurers into paying far higher rates for care than the federal government, could lose billions. And drug companies would face fresh scrutiny and regulation of pricing practices that have allowed the cost of medicines to skyrocket.

"Everyone saw the threat," said one lobbyist involved in the early discussions. "You didn't have to convince anybody that this was a problem."

The Partnership officially launched in June 2018 with five founding members: Kahn's Federation of American Hospitals, AHIP and fellow insurer lobby the Blue Cross Blue Shield Association, drug industry giant PhRMA and the country's premier association of physicians, the American Medical Association.

It's since expanded at breakneck speed, signing up the influential American Hospital Association and some of the nation's largest individual hospital systems; biotech trade group BIO; the health care executive roundtable Healthcare Leadership Council; and a series of trade associations representing smaller slices of the industry like insurance brokers and financial advisers, generic medicine manufacturers and radiologists. Recently, the Partnership branched onto the state level, adding local Chambers of Commerce, industry groups and private companies.

In fact, by earlier this year, virtually every part of the health care industry was on board.

The coalition's ambitions grew with its membership. Initially focused on beating back the Medicare for All movement, the Partnership has since expanded its efforts to oppose all major expansions of government-financed health care.

The industry still views single payer as the doomsday scenario. But by early 2019, it'd become far from the only worrying possibility, as prominent Democrats floated all manner of routes to universal health care. The problem: each achieved their goal in roughly the same way — by having the federal government annex broad swaths of the private insurance market, either by creating a competing public option or expanding the existing Medicaid or Medicare programs deeper into the private sector's territory.

Those plans might sound more palatable to the ordinary American, but to Partnership members it still meant fewer customers, lower pay rates and a new, unnecessary regime of profit-pressuring regulations. So as each 2020 presidential contender rolls out their own signature take on an overhaul, the response from the Partnership has been loud and unflinching: No.

"The politicians may call it Medicare for All, Medicare buy-in, or the public option," reads an ad run by the Partnership during September's Democratic presidential debate. "But they mean the same thing."

Defending a lucrative status quo

The Partnership received $5.1 million in 2018, during its first six months of existence, according to newly filed disclosures — a period that by several members' admission was something of a test run for the coalition. Its current budget remains closely guarded, but members point to the clear ramp-up in activity nationwide this year, a suggestion its spending has grown noticeably. Kahn said only that the Partnership is prepared to spend "many millions."

Measured by sheer size and the financial resources backing it, that would make the Partnership the most formidable source of focused resistance to 2020 Democrats' health plans outside of the Trump reelection campaign.

And they have a lot to protect. The current health care setup is good business for many of the companies represented by those in the coalition. Insurance industry profits ballooned to $23.4 billion in 2018, up from $10 billion a year before Obamacare went into full effect in 2014. The hospital industry has consolidated, vacuuming up physicians and strengthening the nation's largest systems' abilities to negotiate higher rates for care, even as enrollment gains mean they're treating fewer uninsured Americans for free.

Kahn is a veteran of Washington's health care wars, having spent more than four decades in and around Capitol Hill; he’s played a role in every major piece of health legislation during that time.

He also has experience taking down ambitious plans for health care reform. As executive vice president of the Health Insurance Association of America — then the insurance industry's main trade group — he was a driving force behind the "Harry and Louise" TV ads that played a key role in tanking Bill Clinton's health care package in 1993 and setting the standard for a generation of hard-hitting special interest campaigns that have shaped policy debates ever since.

Images from one of the “Harry and Louse” TV ads that helped defeat the Clinton administration’s national health care reform proposal in 1993. | YouTube

The Harry and Louise ads — which featured a middle-aged couple in their home, agonizing over the rising costs and fewer choices under what the ads called Clinton's government-driven system — did little to shift public opinion on their own, studies later showed. But supplemented by grassroots pressure targeting key lawmakers, the television spots and publicity surrounding them unnerved Congress and helped tank support in Washington for Clinton's health plan within a year.

"They weren't run nationally, but the reporters covered them and showed them across the country," Rep. Donna Shalala (D-Fla.), who was Clinton's Health and Human Services secretary at the time, said of the ads. "It was earned media."

The Partnership is now deploying a similar playbook. Run out of a Washington lobby shop and supported by a phalanx of consultants and political operatives, it aims to simultaneously influence voters' perception of Medicare for All and its offshoots, while amplifying doubts about the plans' political viability for the Washington elite.

Outside the Beltway, the Partnership pitches itself as a nonpartisan educational resource on health care. Inside the Beltway, it provides a constant reminder of the power players Democrats are up against if they try for yet another health care overhaul.

The message to both those audiences is simple: Health care reform will take away Americans' "choice" and "control" and empower government "bureaucrats" by forcing everyone into a "one-size-fits-all system." (Medicare for All proponents would counter that few Americans have choice or control now, since insurance is largely managed by their employers, and health care decisions are currently made by insurance, hospital and drug company bureaucrats with little transparency or accountability.)

The group bombards policymakers, journalists and voters with its talking points daily, leaning heavily on digital platforms to reach specific constituencies. Nearly $300,000 in the last year-and-a-half alone went toward Twitter and Facebook messages targeting voters in swing states, the primary battleground of Iowa and the lawmaker-heavy Washington area, according to metrics made public by the social media companies.

Many of those ads feature a local citizen — Matthew Majestic in Macomb County, Mich., Lisa Smith in White Stone, Va. — talking to the audience about government-run insurance systems that will force Americans to "pay more to wait longer for worse care." It's effectively Harry and Louise, if Harry and Louise happened to be real people living in your community. Another several hundred thousand dollars have gone toward similar TV spots, according to filings with the Federal Communications Commission.

Much of this messaging is aimed at eroding support for Medicare for All specifically among Democrats, and the Partnership has leaned on Democrats to make that case.

"You can basically get up to 98 percent coverage through our current structure," said Lauren Crawford Shaver, a former Obama health official who is now the Partnership's executive director and runs its day-to-day operations. "If you use the tools of the Affordable Care Act, if it was fully implemented, you will get more people covered."

The coalition's messages are built on extensive polling and research, and produced with help from Bully Pulpit Interactive, a well-known ad firm that works with the Democratic National Committee and until earlier this year aided messaging for Sen. Elizabeth Warren's Senate campaign. They're designed to emphasize that, while the status quo may not be perfect, it's a safer bet than whatever might come next.

"Building on what we have today and fixing what's broken, not starting over — that earns the most support of any policy proposal," said Phillip Morris, a former Obama field organizer and current partner at public affairs firm Locust Street Group who runs tracking polls for the Partnership.

To reinforce the point, the Partnership churns out reams of research warning of shuttered hospitals, dwindling competition and major shifts in employer-provided benefits under 2020 Democrats' proposals. Federal lobbyists with ties to moderate Democrats encourage the party to keep the focus on pre-existing condition protections and defending Obamacare — issues that paid dividends during the 2018 midterm elections.

And the Partnership is in reporters' inboxes often multiple times a day, highlighting the latest articles and polls casting doubt on any big health care overhaul -- and offering rapid responses to whichever top Democrat happens to be pushing a universal coverage plan that day.

The overarching goal is to create a kind of anti-Medicare for All feedback loop, where the Partnership's warnings are amplified through so many sources that they become ingrained in the national consciousness and make it feel — in perception, and potentially in reality — like the debate is shifting.

"I don't think it's difficult to get Americans worried about health care," said Paul Starr, a Princeton professor who was a senior adviser on Clinton's health plan. "These groups can take advantage of that anxiety."

The doctors defect

The Partnership — as its critics are eager to point out — makes no claim to being a popular, up-from-the-ground movement. The biggest portion of its funding comes from a minority of its membership, and most of the 92 groups listed as Partnership members don't weigh in on its day-to-day strategy in any substantial way.

Two Washington lobbying powers, meanwhile, defected in the past year. The National Retail Foundation quietly dropped out amid its escalating feud with hospital and doctor groups over surprise billing legislation.