The party long bound by a need to defend the Affordable Care Act tries to embrace a new health care vision it can carry into the 2020 presidential campaign. | Justin Sullivan/Getty Images health care Establishment looks to crush liberals on Medicare for All The coalition that fought Obamacare repeal has fragmented as the party tries to follow through on campaign promises.

The united front that helped Democrats save Obamacare just a year ago is falling apart over single-payer health care.

Deep-pocketed hospital, insurance and other lobbies are plotting to crush progressives’ hopes of expanding the government's role in health care once they take control of the House. The private-sector interests, backed in some cases by key Obama administration and Hillary Clinton campaign alumni, are now focused on beating back another prospective health care overhaul, including plans that would allow people under 65 to buy into Medicare.


This sets up a potentially brutal battle between establishment Democrats who want to preserve Obamacare and a new wave of progressive House Democrats who ran on single-payer health care.

"We know the insurance companies and the pharma companies are all putting tens of millions of dollars into trying to defeat us," said Rep. Pramila Jayapal (D-Wash.), who co-chairs the Medicare for All Congressional Caucus. "Which I take as a badge of honor — that they’re so concerned about a good policy that they're going to put so much money into trying to defeat it."

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The rift could come into full view in the opening weeks of the new Congress, as the party long bound by a need to defend the Affordable Care Act tries to embrace a new health care vision it can carry into the 2020 presidential campaign.

House Democratic leaders already are emphasizing the need to align behind a more pragmatic agenda focused largely on shoring up Obamacare, without peering too far into the future.

“We want to continue promoting the idea of accessibility and improving the Affordable Care Act,” said incoming Ways and Means Committee Chairman Richard Neal (D-Mass.). “That should be the primary goal that we have.”

It's a sentiment shared by the major lobbies that fought alongside Democrats against Obamacare repeal and now want to reap the benefits. These interest groups contend that, after a decade of upheaval in health care, the public would prefer simple fixes that strengthen the ACA over a headlong rush into another dramatic overhaul of the system.

But House progressives, buoyed by voter enthusiasm and a surge of single-payer support among the party's base, have other ideas. Among their high-profile agenda items is "Medicare for All" legislation, an idea until recently on the fringes of policy debates that polling shows captivated voters during the 2018 election cycle, despite potentially staggering costs.

"It's more of a mainstream position than it's ever been before," said Adam Green, co-founder of the Progressive Change Campaign Committee, which maintains close ties to House progressives. "There's this hugely rapid advancement toward Medicare for All — single-payer — as not just an eventual North Star goal, but as something that's increasingly possible."

But major lobbies that fought shoulder-to-shoulder with Democrats last year are working now to derail such liberal ideas in order to preserve the status quo.

More than a dozen groups intend to press their point next year through The Partnership for America’s Health Care Future, a vehicle to combat an expanded government role in health care.

America's Health Insurance Plans and the BlueCross BlueShield Association helped found the coalition alongside the Federation of American Hospitals, the big drug lobby PhRMA and the American Medical Association.

Since then, it's added another 13 organizations — most representing companies with much to lose under a system that shrinks or in some cases eliminates private health care.

Medicare for All legislation would effectively eliminate private health coverage. And talk of greater government influence over health care has alarmed providers that contend Medicare and Medicaid currently pay only a fraction of what it costs to care for beneficiaries.

The Partnership, some of whose members began discussions within weeks of Senate Republicans’ failed Obamacare repeal vote in July 2017, is planning to launch a campaign featuring ads, polling and white papers playing up the private sector's role and warning against further disruptions to the health system, people involved with the group said. Avalere, a consulting firm Democrats often leaned on to highlight the dangers of GOP repeal bills, is producing research for the coalition.

Avalere founder Dan Mendelson — a former Clinton White House official — declined to comment on the firm's work, citing a policy of not talking about its clients.

The Partnership has also received support from Lauren Crawford Shaver, a veteran of the Obama administration’s Health and Human Services Department and Hillary Clinton’s 2016 campaign, who is running its operations out of the lobbying shop Forbes Tate Partners.

“We believe all Americans deserve access to affordable, high-quality health care. But a one-size-fits-all, government-controlled system like Medicare for All isn’t the answer,” Shaver said, predicting it would restrict choice and innovation and put “decisions regarding our health care in the hands of politicians in Washington.”

Former top Obama campaign aide Erik Smith has also been involved in running communications for the Partnership, though he told POLITICO his relationship with the coalition is ending in the next few weeks.

Other groups that fought Obamacare repeal are quietly working to limit Democrats' ambitions by highlighting the practical complexities and political risks inherent in rewiring the entire national health care system — including an employer-sponsored insurance market that serves 151 million Americans.

Officials from several groups expressed confidence that public support for Medicare for All will plunge as people become more aware of the trade-offs it would require.

"We are convinced here that, whether it's on the state basis or federal basis, incremental change is a real possibility and is doable," said Kenneth Raske, president of the Greater New York Hospital Association, one of the loudest voices in 2017 against both ACA repeal and a state-level single-payer effort. "In New York, we have 5 percent uninsured. Why do we want to have a 100 percent solution to a 5 percent problem?"

That’s echoed in Democratic circles by strategists fearful of squandering the party's advantage on health care and losing the support of industry groups that have proved helpful in recent health care fights.

Medicare for All skeptics point to the lengths the Obama administration went to secure industry support for the ACA prior to its passage in 2010, an effort that did little to insulate Democrats from eight years of political blowback. Yet another major government health care expansion could be even more painful, they say.

"From a political perspective, it's a really high priority to keep the focus on Republicans and what Republicans have done to harm health care," said Brad Woodhouse, whose pro-Obamacare group Protect Our Care played a central role in the repeal fight. "The country just isn't ready to rip it up and start over again."

Liberals concede their effort faces institutional roadblocks but maintain they're undaunted by the firepower aimed their way.

The House Democrats' progressive wing is increasingly influential, the party has a clear advantage on health care for the first time in years and polls show the once-fringe concept of a single-payer system is captivating a growing portion of the nation.

“We want to make sure we shore up protections for pre-existing conditions [and] do everything we can to make sure the Affordable Care Act is effective as possible,” Jayapal said. “But, in the end, we still have a problem with the cost of health care for ordinary people. And so that’s what we’re trying to address.”

The progressive movement's own lobbying campaign inside and outside Congress is just getting started, she added. That gives the party time to balance shoring up the ACA with figuring out a path to universal health care that could range from incremental steps like adding a public option all the way up to a full single-payer system.

And in the meantime, progressives say they're more concerned about courting voters than winning over big business. For as much as the industry lobbies contributed to defending Obamacare, they argue, the repeal fight demonstrated even more convincingly that Democrats can win any health care battle if the public is on their side.

"People across this country have worked through for themselves the public debate on the government's role in health care, and America has shifted," said Sen. Elizabeth Warren (D-Mass.), a Medicare for All supporter and likely 2020 presidential candidate. "So the importance of persuading every one of the insiders that this is going to be a great deal for them has diminished."

