What’s the Path Forward for Medicare for All?

House Democrats are getting ready to launch a new single-payer push. Do they have a shot?

The post What’s the Path Forward for Medicare for All? appeared first on The Intercept.


In February, House Democrats will be reintroducing legislation to create a universal, single-payer health care system in the United States. Leading the effort will be Rep. Pramila Jayapal of Washington, who chairs the Congressional Progressive Caucus. Ryan Grim talks to Jayapal about her strategy and to Jasmine Ruddy, lead organizer of National Nurses United’s Medicare for All campaign, about the organizing taking place outside of Congress.

[Intro music.]

Ryan Grim: Welcome to Deconstructed. I’m Ryan Grim.

A few weeks ago, for what we thought would be the first show of the New Year, we connected with Congresswoman Pramila Jayapal and Jasmine Ruddy. Ruddy’s the lead organizer on Medicare for All for National Nurses United, a nurses’ union that has been pushing for Medicare for All since its founding. But as we were getting ready to put that show out…

Newscaster: We’re seeing protestors overcome the police. The police are now running back into the Capitol building. We have cheers from the protestors that are watching behind the scenes.

RG: So plans changed, and we re-interviewed Jayapal about her harrowing experience in the House gallery as rioters tried to smash their way through the door protecting her and roughly a dozen other trapped members of Congress.

You can go back and listen to that episode if you haven’t yet, where she also talked about getting infected with Covid after being crammed in a room for hours with maskless Republicans.

Yet as the feds continue their insurrection roundup, there are still more than 30 million people uninsured in America, and millions more underinsured — a crisis at any time, but particularly so in the midst of a pandemic and extreme economic precarity.

Sometime later in February, Jayapal will be re-introducing the Medicare for All legislation she first put forward in 2019, and the nurses’ union is launching a nationwide effort to pressure Democrats to co-sponsor it. The nurses had their first strategy call of the year recently, with over 1,000 activists laying out the plan for the year. They’ll be targeting Democratic members of Congress who are the largest recipients of cash from the health care industry and are standing in the way of reform. At the same time, they’ll be releasing a list of the 10 to 20 Democrats on the fence who can be nudged with a little pressure. They’re also organizing in every congressional district.

In the meantime, the pandemic is opening up opportunities to immediately expand public health care to millions who need it.

For more on that, we’re joined by the chair of the Congressional Progressive Caucus, Rep. Pramila Jayapal, congresswoman who represents Seattle, Washington.

Congresswoman Jayapal, welcome back to Deconstructed.

Rep. Pramila Jayapal: Thank you so much. It’s great to be with you.

RG: So two years ago, back in January 2019, after the midterm blue wave, Democrats had just taken over Congress, Pelosi is running for another term as speaker. What was the Congressional Progressive Caucus thinking? What was the strategy going into those negotiations two years ago, over the rules package over committee assignments, over votes for leadership? What were your priorities? And how did you go about trying to achieve them, then?

PJ: Well, our number one priority was to actually change the composition of key committees that have a lot of authority around budgetary implications, and also progressive policies that are very important to us.

And so what we realized in doing our assessment is that progressives are really underrepresented on those key committees, like Appropriations, and E&C, and others. And so we went into Pelosi and the negotiations and said: “We want, as a top priority for progressives, to make sure that we have at least 40 percent representation, which is the representation of progressives in the Democratic Caucus.” And she agreed to that, which was a big step forward. And we were actually able to get progressives on key committees.

Now, we learned some things out of that. We learned that we should be very specific about who we want on those committees, and make sure that those people were really tied into the progressive agenda.

RG: Mhmm. To unpack that, I think what you’re referring to is that, for decades, the Congressional Progressive Caucus was you just kind of signed up to be in it. And so you had a lot of people in it who were also in some of the more right-wing ideological caucuses. And so what you’re saying is that in a few cases, she met that target by saying, “OK, well, here’s somebody from the CPC.” And you’re like, “Oh, that’s not exactly what we meant.”

PJ: [Laughs.] Yeah, that’s right. And we actually had some people maybe even sign up for the Progressive Caucus right before that happened. So that led us to really consider the rules and reforms package that we passed this year, and also our own CPC reforms package this year in terms of what we wanted to prioritize.

We did also ask for elimination of PAYGO. But I will say that it came very late in the game; we hadn’t done the work ahead of time.

RG: Almost on the day of the vote, or the day before the vote?

PJ: Pretty much. Pretty much. People in the progressive movement sort of elevated that as a priority the day of the vote. And it was too late, you know? With these negotiations, you really have to do a lot of work ahead of time. And so we decided that we would prioritize PAYGO reform and MTR reform, that’s the motion to recommit, which has also really been used against us multiple times to try to weaken legislation on the floor and essentially cause us to bargain against ourselves.

RG: Right, and for people who don’t live this, motion to recommit for years has been the opportunity for the minority party to get a vote on the House floor in opposition to whatever the majority is putting on. And it’s really, basically always used for mischief.

PJ: Yeah.

RG: Like, just trying to force the other party to take some uncomfortable votes. There’s really no purpose beyond that.

PJ: That’s right. Historically, the motion to recommit is basically a tool for the minority party to have a final opportunity — not consistent along the way — but this is the final opportunity to weigh in on legislation outside of what is the regular amendment process. But the modern motion to recommit has gone so far from that original intent.

RG: [Chuckles] Mhmm.

PJ: And now, it is essentially a surprise policy proposal. Members see the text of a motion to recommit literally 10 minutes before we vote on it, and it undermines the spirit of regular order and thoughtful legislating. And really, it’s just minimal, superficial, gotcha debate.

RG: Right.

PJ: And usually, it’s used as a partisan ploy to offer poison-pill legislative changes, often related to immigration, criminal justice reform, bad things that then can be used on a TV spot.

The Republicans, historically, because it was procedural, they always voted against a Democratic motion to recommit when Democrats were in the minority. Democrats, unfortunately, did not do that. We did not hold together. And we often had some of our conservative Democrats voting with Republicans on those motions to recommit. So it was no longer procedural; it was really terrible and often targeting communities of color.

RG: Right.

So you wrote in your memoir that the surprise PAYGO fight of two years ago — that kind of blew up over the course of a day — actually ended up having some positive repercussions for Medicare for All. Can you explain a little bit about how that came about?

PJ: Yes, it seemed like a strange opportunity, but one of the things I’ve learned in politics is you got to take every opportunity you can find. And so when the PAYGO issue suddenly blew up, we had the opportunity to say to the speaker that if we did not get a significant progressive win into commitment from her that we would not be able to support the rules package. And that win was getting her to actually approve of and allow it to happen, because that’s how these things go, hearings on Medicare for All. That was the first time in the history of Congress that we’ve had hearings on Medicare for All. There was no actual legislative proposal, like the bill that I introduced in 2019, a 140- plus page piece of legislation; before that it had just been a 17-page resolution for Medicare for All, and we turned it into actual legislation of how this would work. The speaker agreed to that and we were able to, for the first time in the history of the House of Representatives, have hearings in key committees: the Rules Committee, the Ways and Means Committee, and the Energy and Commerce Committee on Medicare for All, with our hearings, the powerful testimony of Adi Barkan and of Don Berwick, the former administrator for Medicare and Medicaid Services, who came and actually testified about why this was important. And we were able to bat back, frankly, so much of the Republican criticism, and build momentum for our organizing effort across the country.

RG: What was the effect of those hearings internally?

PJ: Well, it was really great, because we have, I think brought on many Democrats who were nervous, frankly, about signing on to a piece of legislation that’s 140 pages that has a lot of detail in it. It’s a lot easier to get Democrats to sign — or anyone — to sign onto a resolution that’s 17 pages then it is something that has detail that you have to commit to.

RG: Now there were some pundits and left-wing media personalities ahead of this vote who were urging you guys — urging the CPC — to use the vote for speaker as leverage to extract a floor vote on Medicare for All. Why didn’t the CPC end up taking that particular route?

PJ: Well, I’m sympathetic obviously, as the lead sponsor of the bill, to people who are frustrated that we have not moved to a single-payer system yet. But the reality is that this is a very slim margin. The vote for speaker was between Kevin McCarthy and Nancy Pelosi, and throwing the entire chamber into chaos would have been very detrimental for the Electoral College vote and everything else.

But more importantly, from my perspective, again as the lead sponsor of the bill, who’s done so much to try to build momentum and get sponsorship and move the bill forward in the legislative process, I didn’t think it was a smart idea. I mean, for us to force a vote on Medicare for All before we are sure that we have the support, I think is a bad strategy. I think that if you are going to argue that the thing that we get from the vote is we find out who’s for Medicare for All and who isn’t, and then we try to primary the people that aren’t — the reality is, you already know that.

I mean, the people who are for Medicare for All have signed on to the bill. The people who are not for Medicare for All have not signed on to the bill. So I don’t know what we get by saying, “we’re going to force a vote,” have the vote go down, and for the people who think that it’s going to pass, I can guarantee you from everything I’ve seen in Congress, that it would not pass. We could do a lot to try to get more people to vote for it than are signed onto it. But it still wouldn’t pass. We just don’t have the majorities we need. And I think at this point with a president, a Democratic president, who has clearly staked out his ground not for Medicare for All, I think we’ve still got work to do as a movement to actually be able to pass these things through.

RG: There was a sense among some people that that this moment was the moment that progressives in Congress had to use their leverage and with this gone there’s no more leverage left. What’s your analysis of that position? And what leverage does the CPC have going forward?

PJ: Well, we have a lot of leverage, because it’s a slim majority. At the same time, what I always tell people is: Remember that if we have a lot of leverage, so do others. So anytime you have a slim majority, and I served in the minority in a state senate, where all the power went to the middle, or the most conservative Democrats and the most liberal Republicans. Because if you’re a progressive, if you want to say, “Well, I’m going to withhold five votes” — or 10 votes, or whatever it is — “for this bill,” then if the bill suffers a defeat, the way that it’s countered by the rest of the chamber is to make it more conservative, and to actually get five Republicans to vote for the bill.

So I think people just have to understand we’ve got to do this carefully, and thoughtfully, and well in advance. Things that come up at the last minute are generally very difficult to get through unless you’ve already been negotiating.

RG: And when it comes to your leverage, it seems like what you’re saying is that you would need to find bills that the House leadership can’t move to the right and pick up Republican support. So that that would have to be something that is so toxic to Republicans, that there’s no amount of moving it to the right that could help. And one of those, I guess, would be anything involving the Affordable Care Act.

PJ: That’s right.

RG: The Republicans, just politically, they can’t touch anything close to Obamacare, unless it’s a full on repeal of Obamacare. And so there do seem to be some fixes coming in the House to Obamacare. And I saw Ro Khanna say on Twitter that that might be an opportunity for you guys to have some leverage, because there’s no way Pelosi can go to Republicans and say, “Look, I’m trying to fix Obamacare. But the progressives are demanding this, that, and the other thing, and so I need some Republican votes to help me get these Obamacare fixes across the finish line.” I assume she’d be laughed out of McCarthy’s office for that. Is that the kind of direction that you’re looking at?

PJ: That is exactly right. And if you look at the legislative agenda that the Progressive Caucus just rolled out, what you will see if you look at the health care section for our priorities are the things that we can do with Democrats that won’t get Republican support in overall health care legislation, but why not pass a bill, a piece of legislation, that drops the Medicare age to 50? Because in the context of the Affordable Care Act, the Republicans likely would not support it, but that would not be popular for seniors. So it would be very popular with seniors, obviously, overall. And so I think that these are the strategies that we have to think about.

And we have to be very careful. Progressive Caucus has played both ways on the NDAA, that’s the National Defense Authorization Act. Many of our most progressive members have never voted for an NDAA. Two years ago, we thought we would try a slightly different strategy, where we would work with the chair of the Armed Services Committee, Adam Smith, to get many progressive amendments into the House version of the NDAA, and then hope that they survived in the Senate version. And so a few of us voted for the NDAA to see if that strategy would work; I’m a great believer that you got to figure out what’s going to actually move your priorities.

It did not work. You know, we got them into the House version, and then they all — not all, family leave still ended up staying, in which was a big victory, but most of the things that we really were fighting for — got stripped out of the final version that passed the Senate and the House. That’s an example where Republicans are always going to end up voting for the NDAA at the end of the day. And it’s a tough vote for a progressive to take when the top-line number doesn’t change on military authorization.

So you’re exactly right to differentiate between something like the Affordable Care Act, or potentially even a $15 minimum wage, things that Republicans have said, “No way, we’re not going to do this,” versus for example, perhaps a transportation infrastructure package, or other things like that. H.R.1 is another example where we’re likely not going to get any Republicans on, and so we were able to push last time around for really progressive additions to H.R.1, and we’re going to get a few more this time as well when that bill is introduced in late January.

RG: Right. And that’s the election reform and public financing, matching financing for campaigns, for people who aren’t following that.

So, on Medicare for All, what is the plan going forward? How Xavier Becerra is likely to be HHS secretary. He has supported in the past allowing waivers for states to create single-payer plans, state by state. Is that the route that the movement is going to invest its energy in or what is the strategic path forward if a floor vote isn’t going to get you there?

PJ: Well, I think there’s two parallel paths.

So we will reintroduce Medicare for All, my bill, probably the first week of February. And our hope is to really put pressure on so that we get at least as many co-sponsors as we had last time, hopefully by introduction day, but, if not, soon after that. And we will continue to press for more hearings, which is really the path to laying the legislative Congressional Record for these things, these big policies don’t happen without that. So in Energy and Commerce, in Ways and Means, in Budget, because the Congressional Budget Office just did a great report on Medicare for All and the cost of Medicare for All. And John Yarmuth, the chair of the Budget Committee, is a supporter of Medicare for All. And so we hope to continue to lay that groundwork and continue to push.I don’t think anything is out of the question. I just don’t want to have a vote until I know that it can actually pass. And so we will continue down that route, just as fiercely as we have before.

At the same time. If you look at what I was able to negotiate with Don Berwick and Abdul El-Sayed, the three of us were the Bernie-appointed people on the Biden-Sanders Unity Task Force on Health Care, I was the co-chair, that is a really good roadmap to where we want to go. We weren’t able to get everything into that, but we got some significant victories and wins.

And then related to that, yes, we’ve already requested a meeting with Xavier Becerra, we’re so excited that he’s going to be the new secretary, he certainly understands the importance of a single-payer system, and we hope we can work with him to really get us there and lay the foundations for what will be the most essential piece of providing health care to everyone by moving to just the single-payer system, no private health insurance, everyone able to get the same care, expansive care, that is needed.

RG: And last question, I think one reason that you saw so much energy online, around this fight over the speaker vote and what path to take Medicare for All in comes down to a couple things, and one of it is that the primary is over, the campaigns are over. And so energy that people used to put into phone banking, and knocking on doors doesn’t have a channel anymore, and kind of the movement for Medicare for All wasn’t giving people kind of an obvious way, at the moment, to express their anger. Like, who do we call? Who do we come after to move this forward? So over the next two years, for people who are angry, for people who want to see change happen faster than it’s happening, what can they do on a day-to-day basis?

PJ: Yeah, it’s such a great question. And we worked really closely with the main organizing groups who are all on the same page with me about the strategy here. National Nurses United already has a signature petition campaign that people can go to get Congressional members on board. There’s a whole campaign that Public Citizen has run that they’re going to re-energize again around getting localities and states to pass single-payer resolutions, Medicare for All resolutions.

And there will be moments where we will really need people to weigh in loudly and get some of these things that we’re fighting for into legislation in whatever way we can. I think all of those things will ramp up. And I know this is a really tough time for people. As the lead sponsor of the bill, I’ve done so much work on just trying to establish what we need to establish in order to move what would likely be the most major piece of legislation since Medicare and Social Security into being. That is not an overnight fight; it hasn’t been an overnight fight. The only reason we’ve made the gains we’ve made is because people have kept their energy up and do feel passionately about it. But we just also have to recognize that you have to have the support and you can’t play into the hands of Republicans and others who want to defeat Medicare for All just so that we have a symbolic victory that doesn’t actually move the ball forward. And I think that was the only consideration here is what is really going to move the ball forward and get health care to every single person in this country, no exceptions — everybody in, nobody out.

RG: Congresswoman Jayapal, thank you so much for joining us.

PJ: Thank you, Ryan.

[Musical interlude.]

RG: If the legislative push for Medicare for All is going to have any chance, it’ll depend heavily on pressure from the outside. National Nurses United has been pushing Medicare for All since it was formed as a union. I’m joined now by their lead Medicare for All organizer, Jasmine Ruddy.

Jasmine, welcome to the show.

Jasmine Ruddy: Thanks so much for having me.

RG: So we wanted to have you on to talk about the path forward for Medicare for All, over the next year or two. What does NNU see as the strategic path forward?

JR: For us, I think it’s two things.

First, we see Congress, particularly the House, being really key to the strategy over the next year or two. This has been the strategy that we’ve been focused on for the last two years. And I think it’s the place where we can continue to build a lot of power and make a lot of gains over the next two years for the Medicare for All movement. There’s a lot of organizing work to do in Congress, because while we have record support for Medicare for All among the Democratic Party base, and we have a huge number of cosponsors, 118 last time who are supportive, we also have a majority of the Democratic Caucus who is still not supportive of Medicare for All.

RG: Mmm.

JR: I think second is continuing to organize the movement, organize a mass, grassroots, militant, activated movement for Medicare for All.

I think what’s really great about this moment that we’re in is that there’s record-high support among the public when polled for Medicare for All, but we’re not yet at a moment where that’s quite the same as an organized, activated movement of people demanding Medicare for All.

So I think a lot of the work that’s left to do is to translate a lot of that public support that exists, but it’s fairly passive into an activated movement of people who are coming together and demanding health care for all.

RG: So can you tell us a little bit about who the National Nurses are? Because about 13 years ago, I think it was, I remember I covered a John Conyers event where he was introducing his bill at the time, H.R. 676, which was the single-payer bill that people rallied around. And, at the time, he said he was very, very proud to have the support of the California Nurses Association.

JR: Yeah.

RG: Which is now National Nurses United.

JR: That’s right.

RG: How did California Nurses become NNU, and what has NNU’s role been in the Medicare for All fight over the last decade or so?

JR: Sure. Yeah. NNU, National Nurses United, was founded in 2009, and is a sort of combination of the California Nurses Association, which is still our largest affiliate or chapter to this day, along with a number of other state nurses’ associations. And today, we’re proud to be the largest union of registered nurses in the country. The nurses at NNU have been fighting for single-payer, for Medicare for All, since the early 90s, really, in California.

RG: And what is California’s role in the strategy going forward? Xavier Becerra is on record supporting a waiver for states to create their own single-payer system. How much energy do the nurses plan to put into the Medicare for All movement plan to put into creating single-payer in California?

JR: Yeah, that’s a great question.

I mean, we were certainly really encouraged to see that Xavier Becerra has been appointed Secretary of Health and Human Services, or nominated, I should say. Because for any state like California, to be able to do single-payer on their own requires the waiver — the sort of blessing, permission — from HHS and from the president. So it’s great because Becerra is a supporter of Medicare for All. I think there’s a clear path for the Biden administration to grant that waiver. And for states like California to lead the way. I think that’s going to be an essential part of the work over the next two years.

RG: So Pramila Jayapal has suggested that in the meantime there are some immediate things that could be done, such as decoupling health care from job by enrolling anybody who’s unemployed into Medicare, by allowing anybody who’s up to 25 or so to enroll in Medicare, by reducing the age down to, say, 50 to be eligible. Are these ideas that legislators have come up with in coordination with NNU and other organizations pushing for this? Are these things that you guys are championing this term?

JR: We are really excited to see a number of these different proposals that are sort of being considered. I will say, at the end of the day, our union fiercely champions and will fight for Medicare for All, ultimately. But I do think that we see anything that contributes to the social insurance model of more people being covered — so, you know, expanding the eligibility age of Medicare down to age 50, is a great example. And we don’t support Medicare Advantage or privatized Medicare, but true coverage and health care for more Americans we see as a stepping stone, as something that contributes to genuinely getting more people in the country health care. And we see that as a win.

RG: There’s been a lot of heat around the idea of forcing House Democrats to take a vote on the House floor on Medicare for all. Where did the nurses come down on that tactic?

JR: There was a lot of discussion over it over the last few weeks. And, you know, it’s not something that we supported. But I want to say what I was most excited about to see with this from the grassroots base, the energy and the interest in escalation around Medicare for All.

I think there’s this sort of underlying premise that Covid has made the need for transformational change more clear than ever, and I just couldn’t agree more with that premise. But, you know, we don’t support something that we’re gonna lose, right? I think what’s really important about this fight, in general, as we talk about fighting to win Medicare for All in the United States, is that we’re up against one of the most profitable industries in human history, right? The insurance and pharma corporations have everything to lose. And they’re already spending millions and millions of dollars lobbying against Medicare for All.

I think a floor vote loss in the House, I think would play just right into their hands. There’s some folks who might say that: “Well, we need to get folks on the record, right?” And I think that may be true, but I think we have a lot more to lose than we do to gain out of something like that.

And I think this is a point that’s been made, but it’s worth repeating: We have a target list. The list of targets that’s sort of widely held among Medicare for All activists in the movement is the list of cosponsors. We had one in the last session, we’re going to have one again in just a few weeks when these bills are reintroduced. It’s the list of Democrats who co-sponsor or who don’t co-sponsor. That’s our list, right? That’s the work that needs to be done is that we need to identify who those people are, call them out, and organize in their districts. And that’s exactly the work that we’re focused on at NNU. That’s the work that needs to happen over the next year, over the next two years. That’s that’s slower, deeper organizing work at the local district level, but I think it’s really critical. At the end of the day, that’s what’s gonna work and there aren’t any shortcuts.

RG: And the thing about a floor vote is Republicans get to vote on the floor then too, and so, back of the envelope, I would guess that there would be more than 300 votes against Medicare for All. So you’d be looking at something like, low 300s to low 100s or so, but the House position on Medicare for All a lot better. If you had to just guess, if you put Medicare for All on the floor tomorrow, as some people were demanding, out of the 435 members of Congress, how do you think that vote breaks down and gets reported in the press?

JR: Yeah, that’s that’s a great question, and a great point, because while we’ve made so much gain in the last session of Congress — I mean, we got up to 118 Democrats in the House, which is really great, right? But it’s also a quarter of the House membership in total, right? I mean, we have still over half of just the Democrats in Congress who are still not supportive of Medicare for All, despite the fact that 88 percent of Democratic Party voters say that they support it, despite the fact that it had huge majorities of support in every single exit poll in the Democratic primaries last year.

So best-case scenario, I think we would have those 118 members. Worst case, I think we have less than that. And we’re talking about a quarter at best. And so I think, I agree, to your point, we’re not just talking about losing a floor vote narrowly. We’re talking about being pretty destroyed.

RG: Right, losing by some 200 votes or so.

JR: That’s right.

RG: So did the organizers of this effort reach out to anyone at NNU? Were you in contact with them over the last couple of weeks?

JR: You know, I wasn’t, but I don’t want to speak if there were any efforts to do so. But I personally wasn’t; I’m not sure about other grassroots organizations that work on this issue.

It was something that did take place over the holidays, there certainly wasn’t very long to consider the strategy or the tactic, I should say. And we have a long-term organizing plan, something we’ve been working on really fiercely for the last two years, and that we’re going to keep working on for the next two years. This tactic doesn’t quite fit into the strategy we’re working on. I wholeheartedly hope that every person who their interest was sparked by this issue, they feel let down or they feel energized, I hope people will join us in our campaign. There’s a lot of work to do, but I hope people will join us.

RG: Yeah, what’s the immediate thing that’s next for this fight?

JR: Again, it’s that district-level organizing work that really needs to happen. So particularly if you’re listening to this, and you know that your rep is a Democrat and they don’t support Medicare for All, we need more local organizing in those districts. Those folks have to be held accountable. That’s the work we’re focused on.

RG: Well, Jasmine Ruddy, thanks so much for joining us on Deconstructed.

JR: Thanks for having me.

[Credits music.]

RG: That was Jasmine Ruddy, and that’s our show.

Deconstructed is a production of First Look Media and The Intercept. Our producer is Zach Young. The show was mixed by Bryan Pugh. Our theme music was composed by Bart Warshaw. Betsy Reed is The Intercept’s editor in chief.

And I’m Ryan Grim, DC bureau chief of The Intercept. If you’d like to support our work, go to theintercept.com/give — your donation, no matter what the amount, makes a real difference.

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See you soon.

The post What’s the Path Forward for Medicare for All? appeared first on The Intercept.

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