As ‘Medicare for All’ Bill's Authors Demand Action, Some Democrats Fear Party Fracture

After months of debate among 2020 presidential candidates and the electorate about what exactly the contentious catch-all term “Medicare for all” entails for the 116th Congress, there is a clear answer — spelled out in the House Democrats’ Medicare for All Act of 2019, unveiled by lead sponsor Rep. Pramila Jayapal (D-Wash.) on Wednesday.

Jayapal’s bill satiates the progressive appetite for health reform -- a decades-old platform that seeks to ensure health care access to everyone and distill the web of patients, providers and insurers down to one point of payment: the government. But the political baggage of the phrase accumulated over the last several years has caused a rift between Democrats who want a complete overhaul of the U.S. health care system and those who want gradual changes -- a divide that both Republican and Democratic strategists say could endanger the movement toward universal coverage.

When asked during a call with reporters Tuesday about what she saw as the biggest challenge to the bill, Jayapal named two major hurdles in the battle ahead: special interest groups and other lawmakers “who are afraid to take on such a big challenge and might feel more comfortable taking on something more small.”

Democratic strategist Colin Strother, a consultant for Rep. Henry Cuellar (D-Texas), said Democrats have “a branding issue” with the phrase “Medicare for all.”  

“‘Medicare for all’ implies some sort of government giveaway,” he said, and “that’s not what Medicare is to begin with, and that’s not what ‘Medicare for all’ would be. Using the phrase makes it easy for people to understand, but it’s not a good brand for marketing it to the national audience.”

Chris Holt, director of health care policy at the American Action Forum and former health adviser to congressional Republicans, said the Democrats could learn from the failed GOP effort to “repeal and replace” the Affordable Care Act as they push “Medicare for all.”

Democrats won on health care in the midterms, he said, but without coalescing around policy ideas, “you end up in the same situation” as Republicans did in 2010 and subsequent elections.

“You’ve made this promise over and over again, but you can’t deliver on it because you don’t actually agree on how to get there,” Holt said.

But Rep. Mark Pocan (D-Wis.), co-chair of the Progressive Caucus, brushed off any concern that in-party conflict could be dramatic enough to distract his colleagues from the party’s unified goal of universal coverage.

“Almost every presidential candidate is trying to talk about it in some way,” Pocan said in an interview Wednesday night. “That says more than any special-interest lobbyists who are hoping it fractures the party.”

A road map for how Democrats plan to provide health care for everyone in the United States, the bill is the most transformative single-payer proposal yet, calling for implementation within two years, a generous slate of benefits eclipsing those offered in Sen. Bernie Sanders’ (I-Vt.) 2017 bill and the abolition of patient cost-sharing. The role of private insurers would be restricted to selling coverage not offered by the federally run program.

Capitalizing on the reality that most Americans conflate losing their private plan with losing access to their doctors and hospitals, industry players have joined forces to oppose single-payer legislation -- pulling some Democrats to their side of the line while others, such as Jayapal, stand their ground.

Avik Roy, president of the Foundation for Research on Equal Opportunity and health adviser to former Massachusetts Gov. Mitt Romney’s 2012 presidential campaign, noted the emergence of two distinct camps within the Democratic Party -- one calling for complete overhaul, and the other for incremental changes to the status quo. This split gives Republicans a chance to unite on solutions tackling health care affordability, he said.

If supporting the elimination of employer-sponsored plans becomes a litmus test for presidential contenders, Roy said, it complicates matters for Democrats who don’t want to be seen as hostile to the progressive base.

Democratic and Republican strategists agree that the GOP fumbled on “repeal and replace” in part because the fervor for repealing the ACA could not compensate for the confusion on how to replace the law. Though Democrats are in a different position because they are driven by a commitment to expand health care rather than political theater, Strother said, they are flirting with the same pitfalls if they cannot couple their zeal for universal coverage with realistic policy.

But Democrats risk alienating progressives if they make any changes to the framework for “Medicare for all” to appeal to moderates.

“The hard-core single-payer people are going to be satisfied with nothing less than that,” Roy said.

Jayapal said Tuesday that she didn’t believe the legislation would fracture the party because it has support from many Democrats who won in swing districts.

“Democrats need to think about who we’re responsive to,” she said. “Of course we stand united in the need to shore up the ACA,” Jayapal said. “But beyond that, we need to move to a transformation. This is a crisis of enormous magnitude, and our response has to be proportional to that crisis. People are dying.”

But the idea of transformation isn't being embraced by some Democrats eyeing the 2020 election. Sens. Elizabeth Warren (Mass.), Amy Klobuchar (Minn.) and Cory Booker (N.J.) have expressed support for buy-in and public option plans, which appeal to those skeptical of the idea that the benefits of introducing “Medicare for all” outweigh the risks of alienating voters who simply want expanded access to a comprehensive health care plan.

“The lesson that we should have learned from the ACA is that targeted reform is more palatable and easier to both market and defend,” Strother said. “Large, wholesale changes are not only off-putting for voters, but create a window for Republicans to parse language, misrepresent things and focus in on the imperfect elements of a bill in order to try and betray the entire contents.”

But Eagan Kemp, a health policy expert at Public Citizen, an advocacy organization involved in constructing the legislation, said that if the goal for Democrats is a single-payer system, proposals that maintain the role of private insurers “entrench corporate interests” and are not an “incremental step” in the right direction -- but rather, move the party away from that goal.

The bill’s outlook is uncertain: There is no guarantee that Speaker of the House Nancy Pelosi (D-Calif.) brings this bill to the floor. Even if it passed there, Pocan said that with Mitch McConnell (R-Ky.) presiding over the Senate, he doubts “Medicare for All” and other public-option proposals will pass this Congress.

Sherry Glied, a health economist at New York University, said the bill is organized as a messaging tool and not engineered to pass -- an observation echoed by GOP strategist Holt. While that’s not inherently negative, Glied said, it contrasts with the health reform bills from the Obama era.

“They were trying to write bills that would pass, to make sure they would get enough votes,” Glied said. “That’s a different way of writing legislation than this. This is written so that every progressive concern is addressed.”

Jayapal, however, rejected any suggestion that her bill was merely a tool to advance debate.  

“This is a real plan,” Jayapal told reporters. “We will be pushing it as far as we can, as hard as we can, as fast as we can.”