This piece first appeared on the Health Over Profit website.

At the start of the August congressional recess, Senator Bernie Sanders announced that he will introduce a senate bill this September “to expand Medicare to cover all Americans.” Since the election, the movement for improved Medicare for all, has been urging Sanders to introduce a companion to John Conyers’ HR 676: The Expanded and Improved Medicare for All Act, which currently has a record 117 co-sponsors in the House and is considered the gold standard by the movement.

Recent reports are that Sanders’ bill falls far short of HR 676 in fundamental ways. In fact, Sanders’ bill is a multi-payer system not a single payer system. His bill reportedly would allow private insurers to compete with the public system, allow the wealthy to buy their way out of the public system and allow investor-owned health facilities to continue to profit while providing more expensive and lower quality health care.

As a leader in the Democratic Party in the Senate, Sanders is trying to walk the line between listening to the concerns of his constituency, which overwhelmingly favors single payer health care, and protecting his fellow Democrats, whose campaigns are financed by the medical industrial complex. Sanders needs to side with the movement not those who profit from overly expensive US health care.

Today, August 30, Health Over Profit for Everyone steering committee members and supporters sent the letter at the end of this article to Senator Sanders raising specific concerns and urging Senator Sanders to amend his bill before it is introduced.

There are two realities

It has become the practice in Washington, D.C., to offer weak bills, which fail to address the roots of the crises we face, to make them “politically feasible.” The Affordable Care Act (ACA) is an example of this. It was a compromise with the health insurance, pharmaceutical and private hospital industries from the start—an attempt to appease them with public dollars in exchange for greater access to care. The ACA was built on a foundation of private industry even though the priorities of those industries are profit for a few, not health for everyone. That faulty foundation has perpetuated the health care crisis—tens of millions without health insurance, tens of millions more who have health insurance but can’t afford health care and poor health outcomes including tens of thousands of deaths each year.

There are two realities that must be considered. The health care crisis will not end until a system is put in place that guarantees universal comprehensive and affordable health care coverage through National Improved Medicare for All or another form of single payer system such as a national health service. That is what we call the “real reality,” and it simply won’t change until there are real changes in policy that solve it. The political reality of what is “politically feasible” is the other reality. This reality will change as people organize and mobilize to demand what they need. Politicians change their positions when they believe it is necessary to maintain their position of power. It is the task of movements to change what is politically feasible.

The movement for National Improved Medicare for All has been working for decades to educate, organize and mobilize the public to change the political reality. And it is working. There is broad public support for Improved Medicare for All and legislation in the House that articulates the demands of the movement. What is needed now is a companion bill in the Senate that is as strong as HR 676. Once that is introduced, activists will work to secure support for it.

Sanders has it backwards. Rather than starting from a position of strong legislation and building support for it, he is starting from a position of weak legislation that he considers to be more politically feasible. By doing so, he is losing the support of the movement that he needs to pass expanded and improved Medicare for all.

Activists versus legislators

This is where it is important to recognize the difference between activists and legislators. Activists and legislators have different priorities. Activists work to solve crises. Their dedication is to an issue. Legislators work to maintain their position, whether it is re-election, seats on committees, good standing with other legislators or continued funding from Wall Street or other wealthy interests. Legislators compromise when they believe it is in their personal best interest. Activists can only compromise when it is in the interest of solving the crisis they face.

To win National Improved Medicare for All, activists need to follow the principles outlined in I.C.U.:

The “I” stands for independence. Activists must keep their allegiance to their issue independent of the agenda of legislators and political parties. The goal is to solve the health care crisis, and politicians from both major parties will need to be pressured to support Improved Medicare for All. Remember, the movement is going against the interests of the big money industries that finance members of Congress.

The “C” stands for clarity. Legislators will attempt to throw the movement off track by claiming that there are “back doors” to our goal or smaller incremental steps that are more “politically feasible.” They will use language that sounds like it is in alignment with the goals of the movement even though the policies they promote are insufficient or opposed to the goals of the movement. This is happening right now in the movement for Improved Medicare for All. Numerous people, who consider themselves to be progressive but who are connected to the Democratic Party, are writing articles to convince single payer supporters to ask for less.

And the “U” stands for uncompromising. Gandhi is quoted as saying that one cannot compromise on fundamentals because it is all give and no take. When it comes to the health care crisis, the smallest incremental step is National Improved Medicare for All. That will create the system and the cost savings needed to provide universal comprehensive coverage. Throughout history, every movement for social transformation has been told that it is asking for too much. When the single-payer movement is told that it must compromise, that is no different. The movement is demanding a proven solution to the health care crisis, and anything less will not work.

The momentum is on the side of the movement for National Improved Medicare for All. Act now to push Sanders to amend his bill so that it matches HR 676. Sign and share the petition tool, and read the letter below to understand the concerns about Sanders’ bill.

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Dear Senator Sanders,

For almost fifteen years the movement for National Improved Medicare for All has organized around HR 676: The Expanded and Improved Medicare for All Act, introduced each session since 2003 by Congressman John Conyers. As you know, HR 676 has 117 co-sponsors so far this year. This legislation is considered by the movement to be the gold standard framework for a universal healthcare system in the United States.

We appreciate your support for Improved Medicare for All and the work that you have done to elevate the national dialogue on Improved Medicare for All. We hope to continue to work with you to make this a reality in the near future.

To that end, we are writing to share our concerns about the legislation that you are planning to introduce. These concerns are based on what we have learned about your legislation without having the benefit of reading a draft of it.

In order to maintain the cohesion and strength of the movement for Improved Medicare for All, the legislation in the senate must be in alignment with HR 676. This is important so that the movement is unified and so that the process begins from a position of asking for what we want and need, rather than starting from a position of compromise. It is the task of the movement to build political support for the legislation in Congress.

Here is a list of our concerns:

1. We oppose the inclusion of copayments and deductibles in an Improved Medicare for All bill. As outlined in the recent letter to you from Physicians for a National Health Program, including copayments adds administrative complexity and creates a barrier to care, which leads to delay or avoidance of necessary care. Economic analyses indicate that the administrative and other savings inherent in a well-planned single payer system offset the added expense of eliminating copayments and deductibles. HR 676 does not include copayments. The movement for Improved Medicare for All has coalesced around the elimination of these financial barriers to care.

2. We support a rapid transition to National Improved Medicare for All. The Medicare system was implemented within a year of passage without using computers. Unlike when Medicare became law, the United States now has basic infrastructure in place for a national health insurance based on Medicare. We urge you to utilize the timeline in HR 676, which would start the universal system in less than two years, rather than delaying or phasing it in by age group over time. Beginning with a universal system allows savings and cost controls that can be used to provide comprehensive benefits without cost sharing.

3. We support a single payer healthcare system. We understand that your legislation will allow employers to continue to provide employee health insurance that duplicates what the national health insurance covers to avoid conflict with the Employee Retirement and Income Security Act (ERISA). We urge you to include a carve out of ERISA for national health insurance so that the new system is a single payer system. Without doing so, your bill will be a multi-payer system. This is required to achieve administrative simplicity and significant cost savings. HR 676 allows private insurance that does not duplicate the benefits of the system. Employers and unions would be able to provide extra benefits beyond what the system covers.

4. We support a universal system. We understand that your legislation will allow health providers to opt out of the national health insurance system. This would create a parallel health system for the wealthy and undermine the quality of the public system. Universal systems are of higher quality than tiered systems because they create a social solidarity in which everyone has an interest in making the system the best it can be. We urge you to reject a tiered healthcare system as healthcare is a human right and should not be based on wealth.

5. We oppose inclusion of investor-owned health facilities. Investor-owned health facilities treat health care, which is a necessary public service, as a commodity for profit. These facilities have an incentive to cut corners, under and over treat and charge higher prices. The result is higher cost and lower quality. We urge you to reject profiteering in the healthcare system so that the bottom line is improving the health of our population, not profits for Wall Street.

The above concerns are based on what we know about your legislation at present. We do not know if they are warranted because we have not read the text. Upon reading it, there may be additional concerns.

We hope that you will share the draft text of your legislation with us and address the above concerns before it is introduced. Our support for your Improved Medicare for All legislation will depend upon whether or not it will serve as a companion to HR 676. If it is, we are ready to work in our states to build political support for it. If the above concerns are not addressed, then your bill will not be a single payer Improved Medicare for All bill and we believe it will undermine the movement for HR 676.

We recognize that legislators tend to compromise from the start to build political support for legislation. This has served as a failed strategy because the final legislation is too weak to accomplish its goals. We suggest a different approach of beginning from a position of what is required to solve the healthcare crisis. We have organized for too long to concede from the start on these fundamental principles.

Signed,

Vanessa Beck, Health Over Profit for Everyone Steering Committee

Claudia Chaufan, MD, California Physicians for a National Health Program*

Andy Coates, MD, past president, Physicians for a National Health Program*

Mary L. De Luca, MD , Child, Adolescent, and Adult Psychiatrist

Dena Draskovich, Leader of Indivisible Omaha and disabled citizen*

Margaret Flowers, MD, director of Health Over Profit for Everyone

Leslie Hartley Gise MD, Clinical Professor Psychiatry, University of Hawai’i*

James S. Goodman, MD, Psychiatrist

Leigh Haynes, People’s Health Movement-USA*

Paul Hochfeld MD, Board Member, Physicians for a National Health Program*

Dana Iorio, ARNP, Board Member, PNHP Western Washington, Board Member, Health Care For All-Washington*

Joseph Q Jarvis MD MSPH, Utah*

Tim Jordan, MD, member, Physicians for a National Health Program*

Stephen B. Kemble, MD, Physicians for a National Health Program advisory board, past president of Hawaii Medical Association*

Edgar A Lopez MD, FACS, member, Physicians for a National Health Program, Kentuckians for Single Payer*

Ethel Long-Scott, Women’s Economic Agenda Project (WEAP)*

Eric Naumburg, MD, co-chair Maryland chapter of Physicians for a National Health Program*

Carol Paris, MD, president, Physicians for a National Health Program*

George Pauk, MD

Julie Keller Pease, MD, Topsham, Maine

Julia Robinson, MD, People’s Health Movement-USA*

Anne Scheetz, MD, Illinois Single-Payer Coalition, Physicians for a National Health Program and steering committee of Health Over Profit for Everyone*

Mariel Scheinberg, OMS 4, Rowan University School of Osteopathic Medicine*

James Squire, MD Physicians for a National Health Program Western Washington*

Lee Stanfield, Health Over Profit for Everyone Steering Committee and Single Payer Tucson NOW*

Bruce Trigg, MD, Public Health and Addiction Consultant

John V. Walsh, MD, California Physicians for a National Health Program*

Robert Zarr, MD, past president, Physicians for a National Health Program*

Kevin Zeese, co-director of Popular Resistance

*For identification purposes only.

Margaret Flowers, MD, is co-director of Popular Resistance and director of the Health Over Profit for Everyone campaign.