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The Democratic Party is quickly coalescing around an ambitious Medicare-for-all platform — and Rep. Pramila Jayapal (D-WA) is shaping up to be a major voice in that debate.
Jayapal co-chairs the Congressional Progressive Caucus and, earlier this week, released a sweeping new plan for single-payer in the United States. Her proposal is arguably the most ambitious we’ve seen yet. It envisions a wider set of benefits and a much quicker transition to government-run health care than the plan offered by Sen. Bernie Sanders (I-VT).
“The problem is if you take too long to transition, then you have a marketplace that knows it’s not going to continue. Therefore, they can hike up prices even more in the interim because it’s sort of operating as a bridge,” Jayapal told me. “So we think that having too long of a transition is actually really detrimental for most Americans.”
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I interviewed Rep. Jayapal earlier this week. We walked through how her Medicare-for-all plan came together, and why she thinks it’s possible — and actually necessary — for the United States to transition from our current system to government-run health care in two years.
“We want to make this as simple as possible, and we believe health care is a human right. It is a right and not a privilege,” she said. “So you can’t say it’s a right just for the people who are not wealthy. You have to say that it’s a right for everybody.”
In this conversation, you’ll get a sense of Rep. Jayapal’s theories of governing, how they differ from those of Obama-era Democrats, and why she doesn’t think she needs buy-in from the powerful hospital and insurance lobbies to pass new legislation.
I spoke with Jayapal while I was guest-hosting The Ezra Klein Show. Excerpts of our conversation, edited for length and clarity, follow.
Sarah Kliff
I was hoping you could start by talking a bit about how this bill came together. I understand you inherited this proposal from other sponsors who had it in previous sessions. Tell me a little about becoming the lead sponsor and how you’ve shaped the bill to make it your own.
Pramila Jayapal
When I got to Congress, I think it was one of the first bills I signed on to. I firmly believe that the market is broken in health care. If we are really going to transition to a health care system where everybody can get quality, affordable health care, then we have to address those issues. We have to move in line with the kinds of policies that every major country in the world already has.
John Conyers had introduced 676 [the bill number for his single-payer proposal] and done a fabulous job. It was an eight-page vision platform for what universal health care could look like. Over the years, he got more and more co-sponsors when he introduced his bill. Even in the last session, I think it only had about 50 or 55 co-sponsors at the start. By the end of the session, it had had around 126. It reflected the push in the country, both from people finally getting some pieces of health care through the Affordable Care Act — which I think really helped us to convince people that health care is a right and not a privilege — and also through Bernie Sanders’s presidential campaign last time around, which really elevated it to the presidential level.
In terms of really putting together a coalition of people who were deeply involved in health care, we looked at Conyers’s bill, we looked at Bernie Sanders’s Medicare-for-all bill, and then we tried to craft a bill that would take the best of both and that would fix a couple of key areas where I felt I wanted to really have my voice on this bill.
Sarah Kliff
And what are the key policy goals you’re thinking about when you’re designing this plan?
Pramila Jayapal
The goal of a Medicare-for-all system really is that everyone is covered for health care and that they don’t have to deal with different points of payment. There is one government-funded health care system that addresses comprehensive needs of people across this country.
I don’t want to buy my coffee from the government. I don’t want to buy my computer from the government. But there are some areas that cannot be centered around profit-making. And that is what this health care system in the United States has become. You have a system where pharmaceutical companies last year alone made a minimum of $50 billion in profits.
We have a system that is being driven by a profit motive instead of catering to illness and helping to deal with illness. This system that we’ve put together in this bill is very similar to Bernie’s bill in the Senate. It’s really about making sure we get rid of all of that noise and have the government do what it should do, which is invest in people’s health and put health over profit.
Sarah Kliff
There are a lot of European countries that have some kind of copay when you go to the doctor. Those copays are usually more affordable than the ones we have here, but they are something. In your bill, there are no copayments or any fees when you go to the doctor. Why go that route? Why not ask the wealthy, for example, to kick in $10 or $20 when they go to the doctor?
Pramila Jayapal
We want to make this as simple as possible, and we believe health care is a human right. It is a right and not a privilege. So you can’t say it’s a right just for the people who are not wealthy. You have to say that it’s a right for everybody. But you also can’t say that only the wealthy should get health care, which is the system we have now.
Everybody should have the right to go to the doctor without that cost sharing. And so much research shows that when you have a cost, even if it’s minimal, it stops people from going. What we want to do is get people to the doctor as soon as they get sick. Preventive care is always less expensive than curative care.
We want to make sure that people get the drugs that they need so that they can take care of whatever it is that they have as quickly as possible. So we don’t want to have copays in here. We want people to have a system where they don’t have to deal with any of that.
Sarah Kliff
When I talk to health policy experts about European systems, one of the things they’ll say is they actually do want people to think just a little bit before going to the doctor. For someone who is decently well-off, or even someone earning as much as Bill Gates, is there any value in asking them to pay something?
Pramila Jayapal
We have been thinking about that for a very long time. That is the only thing Americans have been thinking about for a very long time, so we just don’t have the same problem that European countries may have.
People do nothing but think about health care costs in this country. They wake up in the morning wondering if they’re going to be able to put food on their table or if they should use that money to buy prescription drugs. They wake up in the morning wondering if they should drive to Canada to get their drugs. They wake up in the morning wondering how they’re going to take care of their sick person because that person doesn’t have health care. So, I mean, that is all people have been thinking about.
We want people to contribute their best selves; we want them to be healthy. That is an investment in our economy, and it’s an investment really in who we are as a country.
Sarah Kliff
Do you envision any role for private health insurance in the system you’re proposing?
Pramila Jayapal
Our plan would not use private health insurance. It would be a comprehensive set of benefits and everybody would be covered. Just like in Medicare, we say no duplicative coverage. But sure, if private insurance companies want to, you know, provide plans for cosmetic surgery or some other thing that’s a wraparound benefit ... we believe that the private insurance company will adjust and they will find things to offer to people.
There may be some employers who say, you know, instead of X kind of eyeglasses, we’re going to give you the 3D super-fantastic eyeglasses where you can listen to everybody as you look. That’s fine. They can do that.
Sarah Kliff
What about duplicative insurance? If you look at the Australian system, they let you buy a plan that essentially competes against the government plan and gets you into certain private hospitals with faster wait times. But it sounds like that is not something you would envision.
Pramila Jayapal
Because it really does create a two-tiered system. You see in Germany that if you’re wealthy, you can buy better access. Then you will create that situation where people can buy better access. We don’t want that.
I think if you make $500,000 or you make $50,000 you should have access to the same health care. Congress members shouldn’t have better health care access than workers. CEOs should not have better health care access than the average American. If health care is a human right, then what gives us the right to say it’s a human right, but we’re going to give you the lowest possible plan that you can have if you’re poor? No. If you’re poor, if you’re a working family, if you’re middle class or if you’re rich, let’s all have the same plan for everybody.
Sarah Kliff
You envision a two-year transition to Medicare-for-all after a bill passes, which I believe is faster than Sen. Sanders’s bill, which has a four-year transition. How do you envision moving that quickly — and why that faster transition period?
Pramila Jayapal
This was another area where we looked very carefully. John Conyers in HR 676 actually had a one-year transition. Sen. Sanders has a four-year transition. But the problem is if you take too long to transition, then you have a marketplace that knows it’s not going to continue. Therefore, they can hike up prices even more in the interim because it’s sort of operating as a bridge. So we think that having too long of a transition is actually really detrimental for most Americans. And, and the reality is we already have Medicare and Medicaid. So, you know, a lot of people are already in the system. The systems have to be merged. So one of our plans is merging all the systems, setting up the administration to bring in new people.
Sarah Kliff
That feels very optimistic to me, mostly just from my experience covering the Affordable Care Act and Healthcare.gov. I’m sure you remember when Healthcare.gov launched, it didn’t really work. And they had had a four-year window to set it up.
Pramila Jayapal
The thing is they didn’t combine everything. They still had multiple plans out there. Every state had different procedures. These separate insurance commissions in different states had to be set up. I mean, there were so many things about the Affordable Care Act that were incredible. It expanded access for tens of millions of Americans. But the reality is it didn’t take on that broken marketplace. You don’t achieve the efficiencies, you don’t achieve sort of the speed of transition unless you’re willing to push those things out and really have everything come to one point of contact.
Sarah Kliff
Tell me a little bit about what you’re expecting in terms of the fight over this. I saw you tweeting earlier about a New York Times article about a coalition of folks gearing up to oppose the bill you’re rolling out.
Pramila Jayapal
I think Americans are ready to stand up for something that is a basic human right. And I think there are tens of millions of Americans across this country who want to take on this fight. I think many of my colleagues are ready to take on this fight. We are setting up an unprecedented coalition this time. Obviously we have the presidential candidates and multiple presidential campaigns have endorsed this idea. So we will have a whole different platform, again, to take us to the next level.
Sarah Kliff
There was this theory that President Obama had around the Affordable Care Act that you needed buy-in of industry to pass something in health care. I remember how the White House made sure to get the hospitals and the doctors and the drugmakers all on board with Obamacare before moving forward. Do you operate under that theory? Do you think you need the buy-in of those key players?
Pramila Jayapal
Small businesses are going to be absolutely with us. We have the largest nurses union with us. We have the union that represents long-term care workers. which takes care of a lot of our nurses also, but long-term care workers.
So we will have a number of people — I have had, I will tell you, I’ve had some hospital folks come up to me and say, look, I can’t come out and say this publicly, but you know, we absolutely think this is the way to go. And I think honestly, uncovering a lot of that and allowing it to be okay for people to speak up to have health care as a right and not a privilege is part of what all of this is going to be.
