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Democrats’ historic, messy, first-ever Medicare-for-all hearings, explained

Medicare-for-all gets a hearing in the House.

Ady Barkan (center) attends a Dream Act Now! rally, along with actress Alyssa Milano, in front of the office of Sen. Dianne Feinstein (D-CA), in Los Angeles, California, on January 3, 2018.
Health care activist Ady Barkan (center) at a rally in front of the office of Sen. Dianne Feinstein (D-CA), in Los Angeles, on January 3, 2018.
Gabriel Olsen/Getty Images
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Medicare-for-all is finally getting its first official hearing on Tuesday — followed by a big new analysis the next day.

For single-payer supporters, it is an achievement all on its own that House Democratic leaders agreed to hold a hearing at all on their proposal to completely overhaul American health care. But that jubilation has been tempered by the nagging idea the Democratic establishment is still working to undermine Medicare-for-all.

The Huffington Post reported last week on single-payer supporters worrying that Tuesday’s hearing would be a “farce” because of the initial lack of an outspoken Medicare-for-all advocate on the panel. HuffPost also reported that House Speaker Nancy Pelosi’s office had been intimately involved in planning the hearing — led by one of her top aides Wendell Primus, who has reportedly made dismissive comments about Medicare-for-all in recent weeks.

Some of that anger was mitigated when it was announced on Friday that Ady Barkan, a health care activist and Medicare-for-all supporter who has ALS, would appear on the panel as well.

“It means we’re making progress,” Barkan told me by phone. “We’re putting this agenda in front of legislators, we’re electoralizing it, and we’re building toward 2021, when we’re going to enact it.”

The mood I found people in who have worked for years to move Medicare-for-all into the mainstream was mixed. Some said that more than anything, they wanted respect and felt the best chance to get it was through hearings like the one coming up on Tuesday, where they can show they’ve done the work and addressed concerns more moderate Democrats might have. Others dismissed the hearing as “deliberation theater” that wouldn’t make any real impact unless there was a viral moment.

The insider drama over the hearing’s planning reveals that for as far Medicare-for-all has come, from the left fringe to a congressional hearing, it still hasn’t broken through in the highest ranks of Democratic leadership.

The truth is one panel isn’t going to make or break the plan’s future. Much more important, you might argue, is the report coming the next day from the Congressional Budget Office. CBO is providing an analysis of Medicare-for-all idea, at the request of House Democrats. Given how critical the office’s analysis were in passing Obamacare and sinking Obamacare repeal, the numbers we see in that report will help set the terms of the single-payer debate for the foreseeable future.

Tuesday’s historic Medicare-for-all hearing, explained

The House Rules Committee will convene on Tuesday for the first-ever congressional hearing devoted to Medicare-for-all. They will be formally taking a look at the single-payer plan from Rep. Pramila Jayapal (D-WA), which would quickly phase out private insurance and move every American into a single government health plan that covers almost all medical services at no cost to the patient.

The initial list of witnesses announced on Wednesday suggested a wonky affair — experts from the Commonwealth Fund, the Center on Economic and Policy Research and the National Medical Association were slated to appear from the start at Democratic request. Republican invitees from the Galen Institute and the Mercatus Institute, which authored a lightning-rod analysis of Medicare-for-all last year, were also on the line-up as it was first announced.

But notably missing was any witness who would speak forcefully in favor of Medicare-for-all. That had led to a feeling among some advocates that the hearing would be co-opted into a line-blurring exercise, as much about defending Obamacare as exploring single payer. Per the HuffPost’s Matt Fuller report on Thursday, Pelosi’s office had a heavy hand in setting up the hearing, which exacerbated those fears:

It’s unclear who decided which experts would testify before the Rules Committee. Staffers on the Rules Committee say no one in leadership directly told them this person or that person couldn’t testify, but sources involved with the planning of the hearing say three criteria were applied to potential witnesses: (1) Is this person a leader of a single-payer group? If so, that person could not testify ― meaning Gaffney was out. (2) Is this person an activist? If so, they couldn’t testify. That meant people like Dr. Sanjeev Sriram, who has repeatedly advocated for Medicare for All, were ruled out. And (3) Has this person said anything negative about the Affordable Care Act?

That last requirement, implemented by House Speaker Nancy Pelosi’s top health care staffer, Wendell Primus, according to sources, is particularly an issue for some single-payer advocates, because they believe the hearing could turn into an exercise in which witnesses seem to endorse all sorts of different approaches to health care ― the ACA, a Medicare buy-in situation, and perhaps, maybe, Medicare for All.

According to Pelosi’s office, Barkan’s testimony was already in the works. He texted the speaker on Wednesday and she had passed it along to Rules Committee chair Jim McGovern indicating her support. Barkan’s attendance was announced by the Rules Committee on Friday. The activist had gained attention during the Obamacare repeal debate and because of his ALS, he will testify on Tuesday using a computer system that tracks his eye movements.

“I’m honored to be testifying, and I am grateful that speaker has agreed to hold this first-ever hearing on Medicare-for-all,” Barkan told me. “It is the result of hard organizing of many years. ... Our time on this earth is the most precious resource we have. Medicare-for-all will save all of us tremendous time.”

The Democratic establishment versus Medicare-for-all

On the one hand, the drama over the Medicare-for-all hearing witnesses doesn’t mean much to anybody outside the walls of the Capitol — especially now that Barkan is attending and will provide the forceful testimony in favor of single-payer that supporters desired.

But it still laid bare once again the very serious fractures between the Democratic establishment and the activist left pushing Medicare-for-all, a drama that figures 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. That’s true — and it’s true that single-payer supporters see some value in contrasting themselves with the center left. They are the true believers staging a hostile takeover of a limp liberal party beholden to corporate interests, in their telling of the tale.

Pelosi herself has sounded skeptical about the proposal 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 made by Primus 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.”

The internal Democratic debate is either a mere matter of tactics or a fundamental question of values, depending on which side you’re asking.

“Incremental reforms will leave millions of people without health care. Black people and other people of color, people in rural America, young people trying to start their lives. Which community are you willing to sacrifice in favor of enriching insurance company executives?” Barkan told me. “Half measures are immoral. And they are also ineffective. They won’t deliver the enormous cost savings that will come from Medicare-for-all.”

Complicating matters is that Democratic voters are still figuring out how they feel about Medicare-for-all. A solid majority say they’d support it, but support does dip when some of the talking points against the plan are rolled out. Other more incremental proposals, like letting people buy into Medicare if they so choose while preserving the existing system, are polling even better.

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

Look out for the CBO report after Tuesday’s hearing

Tuesday’s hearing is sure to be interesting — watch for some Democrats talking up other health care plansbut the sneaky truth is Wednesday is really the big day for Medicare-for-all. That’s when the Congressional Budget Office will release a report, prompted by a request from House Democrats, addressing a lot of the big questions about single-payer health care.

CBO is not analyzing Jayapal’s bill specifically, and it may not provide a hard estimate of how much Medicare-for-all would cost. But it still should give us an important window into how the official congressional scorekeepers would go about analyzing a Medicare-for-all bill. These are the various issues House Democrats (via Budget Committee chair John Yarmuth) asked CBO to weigh in on:

  • How a system would be administered;
  • Coverage eligibility and enrollment;
  • What services would be covered and what cost-sharing requirements, if any, would be imposed;
  • What role, if any, private insurers would play;
  • Whether other public programs (such as Medicaid, the Veterans Health Administration, the Indian Health Service, and the Military Health System) would continue to exist;
  • How provider payment rates would be established;
  • What participation rules would be established for providers;
  • What methods would be used to contain costs;
  • How a system would be financed.

The price tag for Medicare-for-all would be politically crucial. Republicans are already running with the $32 trillion figure from the Mercatus report (though that actually showed net savings from what we are currently spending), and wayward Democrats could be scared off by an imposing spending number.

And CBO always serves as the best and last word on how much any given legislation is going to cost the American taxpayer and how it would otherwise affect the people. Democrats made a lot of hay out of the various CBO projections that the Republican health care plans would lead to 20 million fewer people having insurance coverage in the 2018 midterms.

Obviously, plenty of obstacles stand in the way of Medicare-for-all ever becoming reality. A supporter of the plan needs to win the Democratic nomination and then the presidency. Democrats need to win the Senate and then persuade (against all odds) their most centrist members (hello, West Virginia Sen. Joe Manchin) to get on board. It’s a gargantuan political task.

But if it were ever going to happen, this week would be looked back on as the starting point. Single-payer health care is getting the imprimatur of an official congressional hearing, and CBO is starting to look under the hood to figure out how such a plan would work. It’s a big moment for the movement.

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