With the midterms over, a battle over health care policy among establishment Democrats and the grassroots is unfolding. What kind of health care reform should Democrats pursue now that they have won control of the House? This struggle will determine in large part how Democrats will spend the political capital the party has accumulated on the issue of health care. This is a considerable amount thanks to the GOP’s efforts to take health care away from millions and ongoing war against Medicaid. How this battle transpires over the next two years may go a long way in determining if Medicare for All can become policy, or simply remains a “goal” or an “aspiration.”

Single-payer advocates, jubilant about record support in Congress and in public polls, have responded to the midterm success by boldly pushing for a floor vote on Medicare for All (H.R. 676) during the 116th Congress. This move would not result in a law as it has no chance in the Senate. It would, however, represent a huge symbolic victory and, ideally, plant HR 676 as the centerpiece of the Democratic Party’s health care platform.

Much of the work that is being planned by major players in the movement was discussed in a post-midterm strategy call hosted by National Nurses United and attended by Sen. Bernie Sanders, Rep. Pramila Jayapal and speakers from Healthcare-NOW!, Physicians for a National Health Program and Democratic Socialists of America. In the call, Sanders warned of the opposition from “Trump and his minions” and the private health industry. But of all the speakers, only one, Dr. Adam Gaffney, president of Physicians for a National Health Program (PNHP), warned of the dangers posed by Democrats and the threat of “a slew of half-measures.”

Gaffney is right to be concerned about Democrats undermining efforts to improve and expand health care. Since the midterms, so-called moderate Democrats have gone on an increasingly loud offensive for a “practical” alternative to Medicare for All: a public option (also called a Medicaid Buy-In or “Medicare for Some“). The United States of Care, a group started by former Obama official Andy Slavitt that promotes bipartisan solutions, also recently released a memo about various Medicaid Buy-In proposals. The Center for American Progress has offered its own version of this kind of policy, as have numerous legislators.

The basic idea is rather than create a universal health care plan for all, preserve the status quo but add a new optional Medicare product to be sold on the exchange to a limited group of people ages 50-64, although the exact details vary in the many different public option plans that exist (this is a useful comparison of existing proposals). Some advocates for a public option argue it can lead to single-payer, but leaders of the movement and experts on health care argue it would be counterproductive. This is because the public option will attract high-risk patients and would have little impact on costs or access. The primary appeal of single-payer is to benefit from a simplified process and wider risk pool that spreads cost equally across the country. None of this would happen under a public option.

The leading face of this centrist proposal, which would add a limited product to a hopelessly broken market and hijack energy from the single-payer movement, is Rep. Bill Higgins of New York. He is also one of the 123 co-sponsors of Medicare for All in the House, which is rather unsettling to single-payer enthusiasts.

This dynamic raises a serious question that organizers must grapple with. While political pressure from advocates has created many new Democrats who publicly support Medicare for All, there are concerns about the intensity and authenticity of support among many of them. For support to have practical meaning, members of Congress must try to advance the policy. Yet many Democrats made a point to qualify their support for Medicare for All as “aspirational,” and essentially symbolic. With ready-made alternatives to Medicare for All already available, the next big fight for single-payer may not be with Big Pharma or the GOP, but rather, Democrats who insist on putting their energy behind weaker policies.

“If Democrats coalesce around half-measures like the public option, it would squander the political capital Democrats have accumulated on health care on solutions that we know do not work,” Gaffney told Truthout.

This issue highlights what author and activist Norman Solomon says is a “fundamental issue that progressives must deal with in the coming years – and not just for Medicare for All,” but a number of policies.

“It is not enough for Democrats to say they will support something,” said Solomon. “What matters is: Will they advance the legislation? Will they represent the grassroots? This is at the heart of what the grassroots needs to do. We need to hold politicians, even ones we like, accountable for what they do, not just what they say.”

New Democrat Goes on Centrist Offensive

Rep. Higgins, the most visible face of this strategy, is a member of the centrist New Democrat Coalition. He briefly opposed Nancy Pelosi’s speakership as part of a group of hold-outs that mostly stemmed from the party’s right-leaning plank. In explaining his rationale in opposing Pelosi’s speakership, he went on a media offensive in late November to advocate for a Medicaid Buy-In program. This early, aggressive gambit gave centrists a chance to plant flagship health policy for Democrats post-midterm and succeeded in shaping the narrative. “Momentum is building among House Democrats for a more moderate alternative to single-payer health-care legislation,” the Hill reported on November 29.

Despite co-sponsoring Medicare for All, Higgins is clearly not interested in pursuing the reform any time soon. “I support the exploration of Medicare for all, but you have to be well balanced and practical about this,” he said (emphasis added).

The next big fight for single-payer may not be with Big Pharma or the GOP, but rather, Democrats who insist on putting their energy behind weaker policies.

It appears Pelosi and Higgins found common ground (though what their dispute was over a public option remains a mystery). After their meeting, Higgins told the Buffalo News he would give his support to Pelosi and they agreed that he be the lead person on the Medicare Buy-In.

That the pair found common ground is not surprising. Pelosi has long been a darling of the private health industry. She collected more than $500,000 from the private health sector in contributions between 2017 and 2018. The private health industry would prefer a New Democrat like Higgins (who himself collected nearly $115,000 in industry money in 2018) to be the face of Democratic health care reform, as opposed to Alexandria Ocasio-Cortez or Bernie Sanders.

Higgins also has a close relationship with Rep. Richard Neal, the powerful ranking member (and likely the next chairman) of the House Ways and Means Committee, which is one of two committees to have jurisdiction over health policy. (The other one is the Energy and Commerce Committee.) Neal, who has received more than $2 million in his career from the industry, hosted a fundraiser breakfast for Higgins in 2017, indicating a close working relationship.

Rep. Frank Pallone (D-New Jersey), the ranking member of the Energy and Commerce committee, has received about $6 million from the health industry throughout his career and has said, “We [the committee] certainly would consider a Medicare buy-in.”

Single-payer strategists, according to the strategy call made in November, are targeting the chairs of these committees. To date, neither chair has given any words of support for single-payer.

“This is a fight that is not going to be easy,” said Gaffney. “The other side will always have more money and more political connections.”

Democrats: Hedging Their Bets on Medicare for All?

Higgins is hardly alone in showing equivocation in his “support” for single-payer. He supports exploring Medicare for All, but does he support passing it? It has been a common strategy for Democrats to offer co-sponsorship in the face of a mountain of grassroots pressure in the last few years but add a conjunctive adverb (“however,” “but” or “on the other hand”) and various caveats and qualifications.

This was especially evident among senators who co-sponsored Sanders’s Medicare for All bill in 2017. When Sanders’s bill garnered 16 co-sponsors, advocates were elated, and understandably so. In the past, Sanders could not find one solitary co-sponsor in the Senate for any single-payer bill.

But the great lengths some of these politicians went to distance themselves from their own support has been a source of concern among many advocates.

Then-Sen. Al Franken’s response might be the most absurd qualification his “support” for Medicare for All (this came before the Minnesota senator resigned over sexual misconduct):

Establishing a single-payer system would be one way to achieve universal coverage, and Senator Sanders’ “Medicare for All” bill lays down an important marker to help us reach that goal. This bill is aspirational, and I’m hopeful that it can serve as a starting point for where we need to go as a country. In the short term, however, I strongly believe we must pursue bipartisan policies that improve our current health care system for all Americans. (Emphasis added.)

This is about as lukewarm of “support” as you could imagine for a bill that, if passed, would be arguably the most consequential domestic legislation in a generation.

Other Democrats, including possible presidential contenders, followed suit (before Franken’s scandal he had been rumored as a possible presidential contender as well). For instance, Sen. Cory Booker said he would co-sponsor the bill, but in doing so, said he “won’t rest until every American has a basic security that comes from access to affordable health care.

“Access to affordable health care” is not the same thing as a guarantee to comprehensive health care. In fact, the statement alone cedes health care as a commodity, which is not very different from the language the GOP used to try to make its reforms sound palatable — “universal access.” In countries like Canada, Japan and the United Kingdom, citizens don’t merely have “access to affordable care”; they are automatically enrolled — for life — under the nations’ single-payer systems.

Sen. Kamala Harris of California is also a co-sponsor of the bill, but in a later interview up with the Sacramento Bee, she said, “as we talk about moving toward a single-payer system, I think that there’s certainly momentum and energy around that, and when I get back to D.C., I’ll have a better sense of where people are now that they’ve been home.”

These high-profile equivocations worry some single-payer advocates.

“It has become difficult for any Democratic senator considering a 2020 presidential bid not to co-sponsor Sanders’ bill, a sign that support for single-payer will be the default position,” wrote Jim Newell in Slate. “These [co-sponsors] need to show, in short, that they’re not duping single-payer supporters to get their votes—that they care about single-payer health care as a government program they’re serious about implementing, and not just as a talking point.”

This weak-kneed support is seen outside of Congress as well. For instance, it became common for the press to conclude that former President Barack Obama has “endorsed” Medicare for All, when in fact, his comments were much less committal and somewhat confusing. Obama misidentified Medicare for All as a new idea, though he expressed support for the policy as far back as 2003.

Ocasio-Cortez and the Merits of Primary Challengers

Being concerned about the authenticity of some Democrats’ support for single-payer is one thing. Doing something about it is harder. While many Democrats who have co-sponsored Medicare for All have done so timidly, advocates are reluctant to be too harsh on these politicians. Winning new co-sponsors has been the major priority.

This is one reason why Sanders’s bill did not get specific about financing (the staff chose to release a memo outlining possible ways to pay for the plan). The way his legislation was written allowed senators to co-sponsor without technically supporting any new taxes.

But, given the finite amount of time and political capital that exists, organizers say, politicians can’t play it safe much longer.

“Politicians will try very hard to avoid making hard decisions,” Solomon said. “But eventually, you have to decide: Is health care a right or not?”

“Access to affordable health care” is not the same thing as a guarantee to comprehensive health care.

One way to ensure that members of Congress who are sincere in their support for Medicare for All is to run primary opponents against Democrats who don’t advance single-payer. Many of the self-described Democratic Socialists won in the midterms through their strong support for Medicare for All and refusal to accept money from major corporate donors and the private health industry.

Ocasio-Cortez has endorsed this tactic, not just on health care but on many issues, to reform the party. Her victory is an example of a strong supporter of single-payer running against a politician whose decision to support single-payer was viewed with great skepticism among progressives. Joseph Crowley, was, like Higgins, among the 123 co-sponsors to HR 676 when he lost to Ocasio-Cortez. While Crowley had never endorsed the bill in past congressional terms, he did so in May 2017 after the Sanders campaign managed to push the issue into the national spotlight. Moderates like Crowley felt tremendous pressure from the left to co-sign single-payer.

But voters were not fooled by Crowley’s about-face on Medicare for All. As the public grows increasingly class conscious, they are can better able to distinguish Democrats like Crowley, who is drowning in health insurance money and has virtually no small donors, and a new breed of leaders like Ocasio-Cortez, who do not rely on corporate money and whose support for single-payer comes off as genuine.

“Primary challengers, when credible, can be very effective. Even if they do not win, they often move the incumbent on the issues,” Solomon said. “And they are a way to hold Democrats accountable to what they promise progressives along the way. Voters should make these judgments on who to challenge not on their words, but their actions.”

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