If Medicare for All is ever signed into law, what’s known as the “legislative history” will date back to April 30, 2019, and the first word heard by Congress on the question will have been from activist Ady Barkan. The legislative history will also reveal a quirk indicative of the tensions underlying the fight for single-payer health care: The first-ever hearing on Medicare for All was hosted not before any of the major committees with jurisdiction over the legislation, but instead in the cramped quarters of the Rules Committee, which typically only sets terms under which bills will be considered on the House floor. Rep. Tom Cole of Oklahoma, the top-ranking Republican on the committee, noted the unusually obscure venue for such a major piece of legislation. “There’s a reason,” he said, suggesting that Democratic leadership and the chairs of the relevant committees were reluctant to grapple with the issue. “That’s because this is an extraordinary bill.” Rules Committee Chair Jim McGovern quipped: “I like to think that it’s an enlightened chairman” that motivated leadership to choose his panel for the history-making hearing.

The banter between Cole and McGovern also reflected how far the bill still has to go.

The Tuesday hearing marks the highest point yet in the movement for single-payer health care, which has been debated since the advent of the New Deal. It represents a new phase in the process, coming after an organizing effort grew public support for single payer over the last several years, drawing energy from the 2016 presidential campaign of Sen. Bernie Sanders, I-Vt.. That organizing led to the introduction of the most detailed legislative proposals in the House and Senate yet, followed by the first hearing on Tuesday. The banter between Cole and McGovern also reflected how far the bill still has to go. The two committees with the most significant claims of jurisdiction over the bill are Ways and Means and Energy and Commerce. Frank Pallone, D-N.J., chair of Energy and Commerce, has yet to agree to a hearing, but on Tuesday, Jayapal told reporters that Ways and Means Chair Richard Neal, D-Mass., had agreed to hold one. Neal announced his support of a hearing at a private Congressional Progressive Caucus gathering that met as the Rules Committee hearing was ongoing. Budget Committee Chair John Yarmuth, D-Ky., has said that he will also hold a hearing on Medicare for All, though he hasn’t scheduled a full hearing with a variety of witnesses. He has requested that the Congressional Budget Office analyze elements of the bill, a report expected to be released Wednesday afternoon. He plans to follow up by inviting the CBO to testify about the results. The Oversight and Government Reform Committee also has jurisdiction and its chair, Rep. Elijah Cummings, D-Md., is a supporter, though that committee has not scheduled a hearing either. The bill that was the subject of Tuesday’s hearing was authored by Rep. Pramila Jayapal, a Democrat from Washington state and the co-chair of the Congressional Progressive Caucus. It would enhance Medicare’s benefits; eliminate copays, deductions, and premiums; and extend coverage to all American residents. The bill’s legislative progress dates back to Rep. Nancy Pelosi’s fight to become House speaker and pass a reformed rules package, during which Jayapal extracted a series of concessions to hold hearings. But without a hearing or vote in major committees, it’s unlikely to get a vote on the floor of the House this term. In the Senate, meanwhile, Majority Leader Mitch McConnell, R-Ky., has suggested that he may hold a version of a vote, but only as a way to try to put centrist Democrats in a tough spot. Given that Medicare for All isn’t a threat to become law while Donald Trump is in the White House and Republicans control the Senate, the hearing took on a collegial feel. “It’s a noble and worthy goal you all share,” Cole told the supporters of Medicare for All — while going on to dub the means toward that end as a “socialist proposal” and “Medicare for None.” The hearing gave Democrats a chance to have a serious debate on policy, as they lay the groundwork for how they would govern if they were to win the White House in 2020. Many of the presidential hopefuls support Medicare for All, though they have different ideas about how it would take shape. Public support for Medicare for All has increased in recent years, with a majority of Americans backing it in theory, though a recent Kaiser Family Foundation poll found that support drops when people are asked about the details of the plan.

Ady Barkan testifies before the House Rules Committee at a hearing on a Medicare for All bill for government-provided health care on April 30, 2019. Photo: J. Scott Applewhite/AP

When the witness list was settled on for Tuesday’s hearing, advocates were frustrated to find that some of the most high-profile supporters of Medicare For All had not been invited, which suggests another tension: The more seriously the bill is being considered, the more it moves away from its cadre of core original supporters. McGovern said afterward that he didn’t want to stock the panel with veteran pro-single-payer advocates, but wanted to mix in different perspectives. The pressure was eased late last week when it was announced that Barkan, who is universally well-regarded across the Democratic Party, would be taking part as well. Dying of ALS, Barkan spoke with a computer-generated voice, relying on software that tracks his eye movements to enable him to type onto a screen. He told the committee that objections related to cost of single payer are political, not economic, and that the “richest country in the world” can afford to provide health insurance to its people. He also spoke of his personal experience being denied care by insurance companies and needing to spend his precious remaining time battling with them. His home health care costs are running at $9,000 per month, he said. McGovern said Pelosi was the one who suggested inviting Barkan. She met briefly with him ahead of the hearing in a side room, where he showed her his software-driven communication technique. During a recess, Rep. John Lewis, D-Ga., a civil rights icon, also paid his respects. A broad swath of activists, staffers, and lawmakers attended the hearing, further signaling its importance. Staffers for Sen. Bernie Sanders, I-Vt., attended and helped organize the hearing; the bill’s sponsor, Jayapal, attended, despite not being on the committee, and sat beside Barkan. Rep. Ilhan Omar, D-Minn., stopped by to give Barkan a hug and also sat by his side briefly as he testified. Linda Sarsour, one of the founders of the Women’s March, and Winnie Wong, a senior adviser to Sanders’s 2020 campaign, were on hand, as were Jennifer Epps-Addison and Ana Maria Archila, co-executive directors of the Center for Popular Democracy, where Barkan works.

After Barkan’s moving testimony, the panel turned to Charles Blahous, an economist at the Koch-funded Mercatus Center. He talked about his analysis that projected costs for a 2017 version of the Medicare for All bill, which he pegged at $32 trillion over 10 years — far too expensive, he suggested. “Are economists always right?” asked McGovern, jokingly. He then asked Blahous whether it was fair to characterize his analysis as saying “Medicare for All would cost a little more or a little less than we’re currently paying, is that right?” “I think that’s fair,” Blahous said. “We have all these warnings about the high costs,” McGovern said, referring to one of the most common criticisms of single-payer health care. “I mean, we’re spending an awful lot on health care right now.”

Blahous’s emphasis on cost ignores the current system’s trajectory.

Blahous’s emphasis on cost ignores the current system’s trajectory. A recent projection from the Centers for Medicare and Medicaid Services expects national health care spending to reach $6 trillion by 2027, growing at an average rate of 5.5 percent over the next decade. Costs will need to be kept down, either through the current approach of rationing care by making it too expensive for some, or through a single payer that negotiates lower rates across the industry. As conversations about health care tend to do, Tuesday’s hearing veered toward the philosophical. The concept of time, which is at the center of existential thought, came up frequently. “My time to deliver this testimony is running out. And, in a much more profound sense, my time to deliver this message to the American people is running out as well,” Barkan said during his opening statement. “Our time on this earth is the most precious resource we have. A Medicare for All system will save all of us tremendous time. For doctors and nurses and providers, it will mean more time giving high-quality care. And for patients and our families, it will mean less time dealing with a broken health care system and more time doing the things we love, together. Some people argue that although Medicare for All is a great idea, we need to move slowly to get there. But I needed Medicare for All yesterday. Millions of people need it today. The time to pass this law is now.” Rep. Ed Perlmutter, D-Colo., highlighted the waste and inefficiency of the system. “Time is really a key piece of all this,” he said. During questioning, Barkan told the panel members that he appreciated the opportunity to be there, but it wasn’t where he wanted to be. With time short, he’d prefer to be home in California, he said, playing with his son Carl, rather than on Capitol Hill trying to wake up the representatives’ consciences. Rep. Jamie Raskin, D-Md., picked up on the theme and referenced a metaphor made by writer Susan Sontag: “Illness is the night side of life, a more onerous citizenship. Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.” A basic sense of democratic solidarity, said Raskin, meant that those in both kingdoms should take care of each other. Barkan, through his computer-generated device, told Raskin that 10 years ago, he saw the representative speak. “I decided you were the kind of lawyer and public servant I wanted to become,” Barkan said. Testifying for the minority, Grace-Marie Turner, president of the Galen Institute, an organization that promotes public policy research on free-market ideas for health care, raised concerns about rationing health care and extreme wait times for citizens in countries that already have single-payer systems, like France or the United Kingdom. But some of those countries have already addressed long wait times, Sara Collins of the Commonwealth Fund, called to testify by the majority, pointed out. “It doesn’t mean the single-payer system there is going to be the single-payer system here,” Collins said. The fact that insured people in the U.S. still can’t get coverage they need, or choose to go without care over paying exorbitant costs, essentially means that we, too, are rationing care, Farzon Nahvi, an emergency room physician at NYU Langone Health, added. Barkan used the opportunity to resurface a central point of his testimony. “Anecdotes aside, we know that single-payer systems in other countries have better outcomes than we do,” he said.

“We denied her $300, but now we’re paying thousands of dollars for that.”

Nahvi shared a number of stories that highlighted how the current system is not just cruel, but also ineffective and even counterproductive. He talked about one patient who declined to be treated for appendicitis because she couldn’t afford the CT scan and subsequent treatment. Another young woman came in to be treated for a routine urinary tract infection, but her insurance company denied her claim for antibiotics, and she couldn’t afford the $300 medicine, Nahvi said. Instead, she bought some cranberry juice. Two days later, she was back at the emergency room with sepsis and a high fever. She had to be admitted to the hospital. “We denied her $300, but now we’re paying thousands of dollars for that.” Another one of Nahvi’s patients couldn’t afford antibiotics for a fever, and decided instead she’d be better off going to a local pet store and buying antibiotics meant for fish. She overdosed and ended up in the emergency room days later with severe side effects that impacted her brain and central nervous system. She later had to be admitted to the intensive care unit. “I’m worried that there’s a lot of finding problems with the solution, rather than finding solutions to the problem,” Nahvi said. “I never want to see another patient who thinks their best option for medical care is to go to a local pet store.” Another theme at the hearing was the racial disparities that exist in the current health care system. Dr. Doris Browne, the immediate former president of the National Medical Association, which represents more than 30,000 African-American physicians and their patients, said that the Affordable Care Act didn’t go far enough in addressing the ways in which the current health care system fails African Americans. “With numerous and often insurmountable obstacles to receiving quality health care,” Browne said in her opening testimony, “people of color experience differences in access to health care, the affordability of these services, implicit biases by some providers, and limited participation in clinical research, which has consequences around viable medical treatments.” Browne, who is a physician and retired military officer, spoke about health equity, which refers to “the state in which everyone has the opportunity to attain their full health potential and no one is disadvantaged.” She said universal coverage is a pathway to achieving that state. “It has the potential to address poverty, inequality, and discrimination. It can also provide a more efficient and effective, cost-savings, health care system for everyone. Because health equity and opportunity are inextricably linked, when equity is achieved, there will be no health disparities. Whether you call it universal coverage, single payer, Medicare for All, or some other label, the label is not the most important point. What is important is that the care must be of high quality, accessible, affordable, comprehensive, and coordinated.”