The Democrats who are still undecided on Medicare-for-all, explained

The most important audience for the House’s latest Medicare-for-all hearing are undecided lawmakers and voters.

House Democrats are holding their second-ever hearing on Medicare-for-all, as the party tries to sort out what its next big step on health care should be.

The Ways and Means Committee hearing on Wednesday differs from April’s historic hearing on Rep. Pramila Jayapal’s Medicare for All Act, which would cover every American in one government insurance plan, in two important ways: For one, it’s being held in a committee that actually has significant jurisdiction over health care policy, and two, the single-payer proposal is being reviewed alongside more incremental plans to expand health coverage.

Democrats broadly agree on expanding government health insurance to more people, but they don’t agree on whether every American should be covered by the same program, as single-payer envisions, or whether more people should simply have the option of buying a public insurance plan if they want to. Otherwise, they could continue carrying private coverage. Jayapal’s Medicare for All Act has more than 100 co-sponsors, but that is still less than half of the House Democratic caucus.

The public and even lawmakers are still familiarizing themselves with the particulars of the single-payer debate, and surveys show opinion is still moveable. Many Democrats, both members of Congress at the Capitol and voters in Iowa ahead of the 2020 election, are still undecided on the best next steps for health care reform.

“Probably a difference I would have would be whether or not … there was still an alternative for people that did not want to do Medicare-for-all,” Rep. Karen Bass (D-CA), a co-sponsor of Jayapal’s Medicare-for-all bill, told Vox ahead of the hearing. “I think it’s an important debate, and it doesn’t mean that everybody in the caucus is wedded one way or another, but if you don’t have the discussion, how do you figure out where you land?”

Recent polling of Iowa Democratic voters found single-payer Medicare-for-all trailing behind other issues, like climate change and abortion and gun control, as a “must-have” when they were evaluating 2020 presidential candidates.

Single-payer advocates feel they have long been fighting not just to sell voters on the issue, but also with their own party’s leadership to get a voice in the debate about the future of health care. As these hearings demonstrate, they have succeeded in moving their preferred plan to the forefront of the health care discussion.

But they still have persuading to do. Wednesday’s Ways and Means hearing and, maybe more important, the 2020 campaigns will be their next chance to make their case to the broader electorate.

The various Democratic health care plans, briefly explained

The official purview of the Ways and Means hearing is “pathways to universal health coverage.” House Democrats have gradually been collecting information and input about how they could construct a single-payer plan or some other expansion of government coverage since they took the majority. The Congressional Budget Office recently issued a report on the different decisions lawmakers would have to make.

“We’re all for universal health care. All of us are for universal health care. Medicare-for-all is just one way to get there,” Rep. Donna Shalala (D-FL), who was Bill Clinton’s health secretary, said. “And the question is ‘Do you want to take that route? Or are there faster, more efficient ways to get everybody covered?’ These hearings are very worthwhile.”

Her undecided House colleagues, Shalala continued, are concerned about “an upheaval in the entire health care system and that people in their districts want to protect the private health care they have, including union members.”

Democrats have a lot of ideas for what they should do next to expand health care. Vox recently examined nine different proposals in Congress. The plans fall into two categories. There are some that would replace private insurance and cover all Americans through the government. Others would allow every American to buy into government insurance (like Medicare or Medicaid) if they wanted to, or they could continue to buy private insurance.

 Javier Zarracina/Vox

We learned these plans are similar in that they envision more Americans enrolling in public health plans. They would all give the government a greater role in everything from setting health prices to deciding what benefits get included in an insurance plan. Experts say all these bills would almost certainly create an insurance system that does better to serve Americans with high health care costs.

But the Democrats’ plans differ significantly in how they handle important decisions, like which public health program to expand and how aggressively to extend the reach of government. Some would completely eliminate private health insurance, moving all Americans to government-run coverage whereas others still see a role for companies providing coverage to workers. Some bills require significant tax increases to pay for the expansion of benefits — while others ask those signing up for government insurance to pay the costs.

Medicare-for-all supporters believe they have momentum on their side.

“I think more and more people are realizing that Medicare-for-all makes economic sense, and not just moral sense,” Rep. Ro Khanna (D-CA) said.

The Democratic establishment versus Medicare-for-all

Before the first hearing on Medicare-for-all in April, there was a procedural spat between the plan’s supporters and Democratic leadership. The former criticized the latter for having a heavy hand in organizing the hearing and initially leaving off any strong Medicare for All supporter from the witness list. Activist Ady Barkan was added to the panel, though, and he gave powerful testimony on behalf of single-payer at that historic hearing.

House Democrats have sidestepped any such complaints this time: Don Berwick, a former leader of the Centers for Medicare and Medicaid Services and a forceful supporter of Medicare-for-all, will testify on Wednesday. He is a powerhouse witness for the single-payer cause.

“I think Don is an all-star,” Rep. Earl Blumenauer (D-OR) told Vox. “I think he’s the best possible witness we could have for that provision.”

But the witness dispute still laid bare — once again — the very serious fractures between the Democratic establishment and the activist left pushing Medicare-for-all, a drama likely to reoccur again and again with the 2020 presidential primary well underway.

Democratic leaders like to say that everybody inside their party is in favor of expanding health care; they’re just debating over how to do it. Still, Nancy Pelosi herself has sounded skeptical about single-payer specifically in interviews over the last few months. In an interview with Rolling Stone in February, she repeated a few times: “How do you pay for that?”

She described herself as agnostic to the Washington Post in April:

“I’m agnostic. Show me how you think you can get there,” Pelosi said in an interview with The Washington Post. “We all share the value of health care for all Americans — quality, affordable health care for all Americans. What is the path to that? I think it’s the Affordable Care Act, and if that leads to Medicare for All, that may be the path.”

She also suggested that Medicare-for-all had become more of a buzzword among political activists in the run-up to the 2020 campaign, a loosely defined concept that few people understood in concrete terms.

“When most people say they’re for Medicare for All, I think they mean health care for all. Let’s see what that means. A lot of people love having their employer-based insurance and the Affordable Care Act gave them better benefits,” said Pelosi, who shepherded the ACA through Congress in 2009 and 2010 in her first speakership.

Adding to that picture were comments one of Pelosi’s advisers made to a group of health insurers last November, first reported by the Intercept, in which he suggested Democratic leadership would be a bulwark against the left’s enthusiasm for single-payer:

Pelosi adviser Wendell Primus detailed five objections to Medicare for All and said that Democrats would be allies to the insurance industry in the fight against single-payer health care. Primus pitched the insurers on supporting Democrats on efforts to shrink drug prices, specifically by backing a number of measures that the pharmaceutical lobby is opposing.

Primus, in a slide presentation obtained by the Intercept, criticized single payer on the basis of cost (“Monies are needed for other priorities”), opposition (“Stakeholders are against; Creates winners and losers”), and “implementation challenges.”

A lot of Democrats are still figuring how they feel about Medicare-for-all

There is real energy for ambitious health care reform after Democrats beat back Republican attempts to repeal the Affordable Care Act. More than half of Democrats say in a vacuum that they strongly support Medicare-for-all. But there is also a real question of tactics. Even supporters like Elizabeth Warren have been more cautious in commenting on what might be possible in the near term.

Democratic voters also don’t seem convinced yet that the party should be rushing to pass single-payer as soon as possible. A CNN survey found that a little less than half of potential Iowa caucus-goers think supporting Medicare-for-all is a “must-have” for them to consider supporting any of the 2020 Democratic presidential candidates. A Kaiser Family Foundation poll last summer found 37 percent of Democratic voters consider a candidate’s position on Medicare-for-all the single most important factor in picking a candidate in 2018 versus 45 percent that said it was very important but not the most important issue. Other surveys have indicated Democrats would prioritize improving the Affordable Care Act over passing single-payer.

The best forum for this debate won’t be Wednesday’s hearing but the 2020 presidential campaign. Sen. Bernie Sanders (I-VT) has already staked out ground as a forefather of Medicare-for-all. But former Vice President Joe Biden, a more moderate voice than Sanders on health care, is leading the polls. Democrats will get a chance to sound off with their votes on the thorny question of idealism versus pragmatism that undergirds so much of this debate.

The health care industry has mobilized against Medicare-for-all because it sees the idea, and even more incremental proposals, as existential threats. But the industry views the vice president as the guy on their side.

“This encapsulates a liberal versus a moderate in people’s minds. People want to beat Trump. They know a socialist can’t. The government isn’t going to fix everything,” a Democratic health care lobbyist told Vox recently. “To that extent, people are waiting for” a candidate like Biden who wants more incremental improvements.

This debate is far from over. Wednesday’s House hearing is the next opportunity for the competing sides to get in front of the public and try to win over their colleagues and their voters back home.