Above photo: Members of the ‘Baucus 8’ and other NIMA advocates hold a ‘Sidewalk Summit’ in early 2010 when the White House excludes them from its Health Summit. Washington, DC.

By Margaret Flowers, MD

Few people outside of single payer activist circles are aware that Senator Sanders introduced an amendment on the Senate floor in December 2009 that would have replaced the Affordable Care Act (ACA) with a single payer health system. It was the first time in the history of the United States that single payer legislation was brought to the floor for a vote. Sadly, it was a Republican doctor who killed the amendment.

This happened during the height of the health reform process in the Senate; the House had already passed its version of the legislation. It was the result of a year of pressure to include a single payer health system, National Improved Medicare for All (NIMA), in the health reform debate, grassroots pressure that included nonviolent direct action.

Throughout the more than one hundred years of efforts to secure universal access to health care in the United States, there have been moments of opportunity to advance the issue followed by setbacks. Such an opportunity arose during the health reform process of 2009 – 2010 and was followed by a decline after the national health legislation, the ACA, was passed in March 2010.

Social movements are like that, they are like waves shaping the shore. A movement needs to watch for those waves and amplify them. Another wave for NIMA is rising because of the obvious failures of the ACA, persistent grassroots organizing by single payer supporters, and the momentum created by the Bernie Sanders campaign, which activated new people and elevated the public dialogue around single payer. This is the time to look back at the lessons of past efforts and consider what can be done in this political moment.

A Watershed Moment for the National Improved Medicare for All Movement

Shortly after the election of Barack Obama in 2008, a coalition of organizations that supported NIMA, the Leadership Conference for Guaranteed Health Care (LCGHC), which had been meeting monthly by conference call for the preceding two years, held a face-to-face meeting to strategize ways to include NIMA in the upcoming health care debate. The coalition included health professional organizations, such as Physicians for a National Health Program, labor unions such as National Nurses United, grassroots organizations, many of which were part of Health Care Now, faith-based groups and political organizations such as the Progressive Democrats of America.

The conditions seemed ripe to move NIMA forward. In 2003, President Obama told a group in Illinois that we would get single payer when the Democrats had control of the White House, Senate and House. Polls indicated that more than 60% of the general public, almost 60% of physicians and 80% of Democrats supported NIMA.

Out of the November strategy session several committees were formed. I was a member of the LCGHC as co-chair of the Maryland chapter of Physicians for a National Health Program, and I joined the lobbying committee. Beginning in December 2008, we met with members of Congress, including leadership, and asked that our proposal for National Improved Medicare for ALL be included. Many members of Congress agreed that this was a reasonable idea. However, as I experienced over the course of the reform process, politicians appear agreeable in order to placate constituents, although they have no intention of following through on what they say.

The first series of three hearings on the health reform legislation was held by the Senate Finance Committee in May 2009.  Max Baucus (D – MT) was chair and he hired Liz Fowler, a former lobbyist for WellPoint (one of the largest private health insurance companies in the US) to lead the health reform process. Fowler, who was called the most influential health staffer in the Senate by Washington Post health reporter Ezra Klein, authored a white paper for the bill in November 2008 and also authored the Senate health legislation.

When we saw that only industry and big business representatives, such as the US Chamber of Commerce and the Business Roundtable, were invited to testify, we pushed for the committee to invite Dr. Marcia Angell, a national health finance expert and former editor of the New England Journal of Medicine. Single payer supporters sent emails and called the committee office, but the day before the second hearing we were told that Dr. Angell would not be invited.

That was a watershed moment. All of those months of lobbying to be included had failed. NIMA was being excluded from the process. In response, eight of us decided to attend the hearing and ask why we would not be allowed to testify. We stood up one by one and spoke out during the hearing about the exclusion of what majorities of people in the US wanted and needed and about the corruption of the committee. And one by one, as the C-SPAN cameras rolled, police were ordered to remove us from the hearing and arrest us. This action received significant attention and we became known as the “Baucus Eight”. The following week at the third hearing, National Nurses United and a few more doctors protested and five more people were arrested, the “Baucus Thirteen”.

As a result, in June, I was contacted by the Senate Health, Education, Labor and Pensions (HELP) committee and asked to testify in their first hearing. And when hearings were held in the House of Representatives, representatives of the single payer movement were invited to testify. It was a positive step, if only designed to placate NIMA supporters.

Through the summer, there was a lot of activity by grassroots activists to push for NIMA locally and in Washington, DC. The LCGHC organized Congressional briefings to educate staffers and in my new role as Congressional Fellow for Physicians for a National Health Program, I organized health professionals and students to meet with health staffers and teach them about NIMA.

The process of health reform in the House stalled because of bipartisan disagreement that summer. Major events were held in Washington, DC and nationwide around Medicare’s birthday at the end of July 2009. There was a large march and rally in DC and hundreds of activists delivered informational ‘birthday cards’ and cupcakes to members of Congress. Interestingly, the only amendment that unified the two parties during the entire health reform process was an amendment offered on July 30 by Representative Anthony Weiner calling for Medicare to be dissolved. It was a test by the NIMA movement and both parties opposed dismantling Medicare.

Congressman Weiner then offered an amendment to substitute NIMA legislation for the House bill. The committee was under pressure because it was close to the August break, and so leadership made a deal that they would allow the amendment to be offered for a vote on the floor of the House if Weiner withdrew it. He did.

The summer break was a crazy time. The right wing fury over the health legislation, funded and whipped into a frenzy by the Koch Brothers-backed group Americans for Prosperity, brought hundreds of protesters out to local Town Halls. They called the health legislation everything that a NIMA system would be called, such as “socialism” and “government-run”, even though the bill was being written by and for the industry and was the opposite of a single payer system. If the Obama administration and Congressional leadership had hoped that avoiding single payer would placate the Right, they were mistaken.

In the fall, NIMA activists also escalated to build support for the single payer substitution amendment. A group of doctors from Oregon organized a road trip from Washington State to Washington, DC called the Mad as Hell Doctors tour. They spent the month of September zig- zagging across the country holding 40 events in 17 states. Their tour culminated with a large rally at the White House attended by health professionals from almost every state. Despite numerous requests for a meeting with the President, they were ignored.

A few of us from the LGCHC formed an independent group, the Mobilization for Health Care Reform, to have more flexibility to organize direct actions. “The Mobe” held national days of protest at insurance companies calling for Improved Medicare for All. Over 1,000 people pledged to risk arrest and almost 200 doctors, nurses and patients were arrested for sit-ins. One group in Louisville was locked in the lobby of Humana overnight without access to food or bathrooms.

In November, just thirty-six hours from the House vote on the health bill, the LCGHC was informed that if the single payer amendment were to be voted upon, then Representative Bart Stupak (D –MI) and Joseph Pitt’s (R – PA) anti-abortion amendment would also have to be voted on. We agreed to withdraw the amendment, though in the end Stupak and Pitts persisted and their amendment went forward and was passed. That was an important lesson – not to be tricked into backing down.

Senator Bernie Sanders introduced a similar single payer substitution amendment in the Senate based on his American Health Security Act, and Senators Sherrod Brown (D – OH) and Roland Burris (D – IL) co-sponsored the amendment.The Senate version of the health bill faced significant struggles, and Senators were under tremendous pressure by the Obama Administration and leadership to pass it before the winter break in mid-December.

The Sanders’ amendment was initially not allowed to be introduced on the Senate floor. Majority leader Harry Reid (D – NV) skipped over it as other amendments were heard. In protest, on International Human Rights Day, “The Mobe” organized an action in which paper cut-outs that looked like chalk outlines of dead bodies were delivered to Senators with a letter describing the number of people in their state who were dying for lack of access to care. Senator Al Franken (D – MN) chastised us for upsetting his staff. By the time we arrived at Senator Reid’s office, CNN and a Getty photographer, Alex Wong, were following us, and Reid’s Deputy Chief of Staff agreed to speak with us.

Perhaps it was the protest and our pleas to Reid’s staffer that pushed the Majority Leader to allow the amendment to be voted on. The action happened on a Thursday and the next Monday word came down that the amendment would proceed. To mark the historic occasion, we held a vigil the night before the amendment was brought to the floor in the atrium of the Senate Hart Building. To make it even more memorable, the late Senator Phil Hart’s daughter contacted us and told us that he was a single payer supporter and he would have approved of our efforts.

On Wednesday, December 16, the amendment was introduced on the floor of the Senate. Immediately, Senator Tom Coburn (R – OK), a physician, called for the 767-page amendment to be read. Sen. Sanders objected, but Sen. Coburn held firm and the reading of the amendment began. For three hours, the amendment was read on C-SPAN and single payer supporters across the country tuned in. But tension was high as the winter break neared, and after three hours, Sen. Sanders made a deal with Sen. Reid to withdraw the amendment. In exchange, he was given thirty minutes on the Senate floor to make a speech. Sanders said, “I am absolutely convinced that this legislation or legislation like it will eventually become the law of the land.”

Obstacles to National Improved Medicare for All and Lessons Learned

Although many people blame the Republicans for the exclusion of NIMA during the health reform process, it was actually the Democrats and progressive organizations that shoulder most of the blame. A tried and true method of weakening a movement is to divide it, and that is what supporters of the ACA did starting in 2008.

The model for the ACA was the health law passed in Massachusetts under Governor Mitt Romney in 2006, which was based on a model designed by the conservative think tank The Heritage Foundation. Shortly after that, state health reform advocates funded by the Robert Wood Johnson Foundation started pushing the same model in other states. There was a big push in Maryland by Maryland Citizens Health Initiative (MCHI). In July 2008, MCHI, labor and progressive groups launched a new coalition to support the Democrat’s health reform. The coalition was called Health Care for America Now, which was based on the name of the long-time single payer organization Healthcare Now. This is a common tactic – stealing the name or slogan of the opposition and causing confusion around it.

Health Care for America Now supported the idea of a public option, a public insurance that they claimed would compete with private insurance and eventually become a single payer plan. From a health policy standpoint, this made no sense because all attempts at this in the past had failed. The private insurance companies attract the healthiest enrollees and the sickest patients wind up in the public insurance, which ultimately fails financially due to the high burden of healthcare costs it carries. But the idea of a public option was successful in fooling many single payer supporters who were told that single payer was not ‘on the table’ and that the public option was their best choice for reform.

Tens of millions of dollars were given to Health Care for America Now, and it was used to control progressive groups. Meetings were held every Tuesday in Washington, DC where organizations were given their marching orders and talking points. Groups such as MoveOn, despite high support among their members for single payer, refused to even allow discussion of single payer and rallied people behind the public option.

Most progressive members of Congress, even those who campaigned on single payer platforms and supported it in the past, also ran away from NIMA. The Congressional Progressive Caucus, the largest caucus in Congress, tightly controlled their members’ talking points and prevented comparisons from being made between the health bill and a single payer bill.

A big problem was that not only would a public option fail, but it was also never intended to be in the final legislation. In March 2009, speaking at the Center for American Progress, Senator Max Baucus stated that the public option was a bargaining chip that would be used to force the private insurance companies to accept regulations. And, the public option did not make it into the final bill. The House bill included a very weak version of the public option, which was tossed during the final negotiations in 2010. The Senate bill did not contain a public option. In December when advocates pressured the Senate to include a public option and they started moving in that direction, the White House and leadership worked behind the scenes to prevent it.

In the end, the ACA was so weak and such a boon for the private insurance industry, that its passage was more about saving the President’s legacy and the face of the party than it was about solving the health care crisis. Many Democrats said they would “hold their nose and vote for it.” Congressman Dennis Kucinich (D – OH), one of the last Democrats to hold out in opposition to the ACA and in support of single payer, was taken for a flight on Air Force 1, the President’s plane, and strong-armed into supporting it. This is a common tactic.

The three lessons that I took away from that struggle conveniently fall into the acronym “ICU”, which can also stand for Intensive Care Unit. I often say that we have a health care crisis and we need the ICU.

The “I” stands for independence. It is critical that social movements remain independent of the agendas of political parties. Social movements should place policy over politics.

The “C” stands for clarity. It is very important for social movements to understand policy and recognize whether the solution they are supporting is a real or a false solution. Single payer is a real solution; it will solve the health care crisis, while the public option is a false solution. Social movements must also recognize misinformation. The ACA was called “universal, guaranteed and affordable” but it would not be any of those.

And the “U” stands for uncompromising. Social movements are often told to be pragmatic and compromise, but to paraphrase Gandhi, “One cannot compromise on fundamentals because it is all give and no take.” The only way that we will achieve the solutions we require is to hold firm in our demand for them. Accepting the argument that we must be ‘pragmatic’ weakens the movement.

Why should we support Improved Medicare for All?

Health advocates are often convinced to support incremental reforms rather than calling for a change as large as National Improved Medicare for All. This is common; social movements have always been told they were asking for too much whether it was for the end of slavery or for worker, women’s or civil rights. In reality, creating a national single payer health plan is the smallest incremental step that can be taken to begin to solve the health care crisis. It is the only way to remove the greatest obstacle to health care in the US, the private insurance companies, and achieve the savings required to cover everyone. It is the only way that health care can start to be treated as a public good rather than a commodity for investors to make profits. There will be much more that needs to be done once NIMA is passed to meet the health needs of the tens of millions of people who are without health insurance or who have insurance but still can’t afford the out-of-pocket costs of care.

National Improved Medicare for All would create a national health care system that covers every person living in the United States. It would be financed through a progressive tax so that the costs are predictable and are paid up front, rather than at the time health services are used. There would not be any insurance premiums, deductibles or co-pays, so there would not be any financial barriers to care. And medical debt, the leading cause of personal bankruptcies and foreclosures, would cease to exist. There would be a single standard of high quality comprehensive coverage for everyone. A similar system, the Veterans Health Administration, has demonstrated that single payer ends disparities in health outcomes, which are widespread in the US.

When people hear about NIMA, often the first thing they say is that we can’t afford it. The reality is that we can’t afford not to do it and we are already spending enough to cover everyone. The US spends the most per capita on health care each year compared to all of the other industrialized countries. The US even spends more in public dollars per capita alone than many countries spend, including countries that have universal high quality coverage and better health outcomes than the US. Numerous studies have shown that a National Improved Medicare for all would be less expensive than the current health system and that it would control health care spending.

One of the biggest wastes of health care dollars in the US is on administration, a third of our health care dollars, hundreds of billions each year, is spent on paperwork to determine what policy a patient has, what that policy covers, where a patient can go for care, how much the patient pays, whether they have a deductible or co-payment, etc. This is because there are hundreds of insurance companies with different plans that have different coverage, provider networks and out-of-pocket costs. The cost of this bureaucracy is a burden to people who have health insurance, because it is included in the cost of the premium, and to health professionals and facilities that have to hire staff on their end to interface with insurance administrators.

A NIMA system simplifies that bureaucracy tremendously. There is one system with one set of rules. The administrative savings are estimated to be $400 to 700 billion each year. NIMA systems also control costs because they can negotiate with pharmaceutical and medical device companies for fair prices. The US spends more on goods and services than other countries because it doesn’t have a coherent system of pricing. And NIMA systems also control costs by giving hospitals global operating budgets so that, rather than charging patients for each individual item (each bandage or pill, etc), hospitals have a lump sum they are given each month to cover costs.

The ACA was sold to the public as a step towards a single payer system, but in fact it took the US healthcare system in the opposite direction, toward greater privatization. Instead of building up our public insurances, Medicare and Medicaid, they are being increasingly privatized through Medicare Advantage Plans and managed care companies. Instead of getting rid of private health insurance companies, the government became a broker for them as people are forced to buy insurance policies. And the insurance companies are given hundreds of billions of dollars each year in subsidies while they continue to pay millions in salaries and bonuses to their executives.

Proponents of the ACA said that it would create competition between insurance companies that would drive them to lower the cost of premiums, but that competition has not emerged and instead mergers are occurring. Insurers continue to try to raise premiums each year by as much as 60%. And private insurers have found new ways to skirt regulations. Although they are required to cover everyone regardless of pre-existing conditions, they have, for example, created ultra-narrow networks that exclude major medical centers where people would need to go for care when they have serious conditions.

The result under the ACA is that tens of millions of people are without insurance, and the system cannot be tweaked to achieve universal coverage because the cost would be unbearable. Tens of millions of people are also under-insured, they have health insurance but they still can’t afford the care they need. The quality of employer-based insurance plans is being eroded as they become less comprehensive and more like the high-deductible plans sold on the health insurance exchanges. And finally, the ACA is under constant legal attack because it is so complex that it is vulnerable. Now that the Republicans are in power, they are moving rapidly to repeal the ACA.

The Democrats are currently working to defend the ACA. Instead of trying to preserve or tweak a broken and failed system, as has been done for decades, it is time to build on what works, Medicare.

How do we win?

The current political environment has brought National Improved Medicare for All back into the public dialogue. Senator Sanders made it a major part of his campaign platform, which sparked attacks from the Clinton campaign despite polls showing strong support for single payer. A Kaiser Family Foundation poll in December 2015 found that six out of ten people support Medicare for All, including eight out of ten Democrats, six out of ten independents and almost 4 out of ten Republicans. A more recent Pew poll shows that 52% of Republicans earning under $30,000 a year believe the government should guarantee that everybody is covered. Public support for the ACA remains low. According to an April 2016 Pew poll, 54% of people say they disapprove of the ACA, only 44% support it, and more people say that it has had a negative impact on the country and on their families than positive.

The Clinton campaign claimed that improved Medicare for All would be too expensive and that it was too difficult to achieve, that the best path was to build on the ACA. When economist Gerald Friedman, who has authored studies of single payer, came to Sanders’ defense, Ken Thorpe, who worked in the Clinton Administration, wrote a widely-publicized analysis claiming that single payer is unaffordable. Thorpe’s analysis made several false assumptions such as low administrative savings, high utilization and no cost savings. In reality, numerous economic studies at the state and national levels, and experience in other countries with single payer health systems, prove that a NIMA system is the most cost effective and is the best system for controlling healthcare costs.

It is not possible to build on the ACA to make it a universal and affordable health system. This mandate model of care has never been able to achieve universal coverage. There have been attempts for decades at the state level in the US to tinker around the edges of the current health system, and none of the changes have succeeded because they do not get at the roots of the crisis. The smallest incremental step that we can take to solve the healthcare crisis is to create a National Improved Medicare for All. This allows the cost savings necessary to provide comprehensive and affordable health coverage for everyone.

For decades, people have accepted tinkering with them system because they have been told that small changes are the only options on the table. They are told that there isn’t political will to pass a single payer system in Congress. Unlike the reality of the health care crisis, which will remain until we take the necessary steps to end it, the political reality can change if people work together to make it so. As the failures of the ACA set in and it is repealed, popular support for NIMA is rising again. It is up to us to seize this moment and push it forward.

The foundation of any movement is education, organization and mobilization. The single payer movement across the nation has laid much of the groundwork. Physicians for a National Health Program has excellent educational materials and more than 20,000 members, many of whom can give talks to community groups and Grand Rounds at medical institutions. There are also grassroots single payer supporter groups such as Heathcare-Now. And National Nurses United, the largest union for nurses, has advocated for Medicare for All for a long time.

The keys to winning single payer are to build a broad movement in support of it and to become more assertive in the tactics that are used. The NIMA movement faces the same obstacles as other social movements, the dominating influence of rich and powerful corporations that control the political system. When single issue movements work together strategically, they have the people power to overcome the power of money.

That is why we created a new coalition organized by individuals who have been involved in or leading the fight for National Improved Medicare for All, including people who committed nonviolent civil resistance. Called “HOPE” for Health Over Profit for Everyone, the group is singularly determined to build a broad-based and assertive movement in support of National Improved Medicare for All to shift the political winds and make NIMA the only viable solution.

Health care is a uniting issue because it impacts all of us; we all need it at some time in our life and we all have either had a personal experience or know people who have been mistreated by the current system. And health is connected to everything; even if everyone had access to care, health outcomes would not significantly improve unless we address the social determinants of health such as wealth inequality, lack of education, homelessness, unemployment and low wages, food insecurity, systemic racism, mass incarceration, environmental toxins, and the climate crisis.

The movement for NIMA needs to frame itself as part of the broader struggle for economic, racial and environmental justice and build relationships with other movements. This is already happening on some fronts. All Unions for Single Payer and the Labor Campaign for Single Payer have worked for a long time to connect single payer to labor struggles. Medical students are taking action in solidarity with the Black Lives Matter movement and environmental justice groups.

As we learned in 2009, escalating the tactics to include protests and other forms of strategic nonviolent direct action will be necessary to advance NIMA. Similar to environmental and climate justice activists who have confronted giant oil and gas corporations to stop harmful projects, and have won in some cases, the NIMA movement will need to confront the medical industrial corporations that prop up the current system. And similar to activists who successfully stopped the Trans-Pacific Partnership, activists will need to pressure individual lawmakers to counter the pressure coming from corporate lobbyists.

Building an effective movement for National Improved Medicare for All means understanding the realities of the challenges we face. The political system is rigged to benefit the wealthy and the medical industries have a lot of resources. The current political system will not put NIMA ‘on the table’ unless a popular movement forces it there. And when it is ‘on the table’, the people will have to fight to advance it.

The good news is that the truth is on our side and social movements have succeeded in the past to win major victories. Moving forward from the popular uprisings that are taking place across the country right now around a number of issues such as systemic racism and police violence, growing poverty and employment insecurity, mass deportations, rigged trade agreements  and war, the time has come for people to work together to set the political agenda from here on. We will not win the changes we need without a broad and activated movement that defines and demands the future we want, including National Improved Medicare for All. Such a movement will be greater and have more of a lasting impact than the current Trump administration.

Margaret Flowers, MD is a pediatrician who co-directs Popular Resistance. She was a candidate for US Senate in Maryland, Green Party.

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