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A Medicare for All Vote Isn’t Worth the Risk

It could leave us even worse off than where we started. There's a better way.

Photo: Molly Adams

Medicare for All has had a pretty horrible year. For about a month in February, it looked like the biggest champion of single-payer in the U.S., Bernie Sanders, was on the path to winning the 2020 Democratic presidential primary. Then came South Carolina, a few calls from Barack Obama, the consolidation of the few remaining candidates of the Democratic center around Joe Biden, and Super Tuesday. By the time the full gravity of the coronavirus pandemic hit most Americans, the biggest anti-Medicare for All Democrat in the primary had all but sewn up the nomination.

Popular support for Medicare for All steadily grew as the Sanders movement gained strength, and now appears to be holding firm, but the crushing of the Democratic left and the party’s anemic performance in 2020 have combined to make a single-payer system appear as far away as it’s ever been. In fact, the number of co-sponsors on both the House (118) and Senate (14) Medicare for All bills in this Congress actually dipped slightly from where they were in the last Congress (124 and 16, respectively).

Most people on the left are rightfully demoralized and frustrated about this predicament, and there’s no real easy answer to what comes next. All of this makes the current blow-up in left media—over the utility of pushing the most left-wing members of the House to withhold their vote for Nancy Pelosi for one final term as Speaker in order to force a floor vote on Medicare for All—very understandable.

On one side of the argument are a sizable number of people on the left, most prominently commentator Jimmy Dore and former Sanders press secretary and writer Briahna Joy Gray. They have said that Alexandria Ocasio-Cortez and other members of the Squad should use their leverage against Pelosi—who will have the slimmest Democratic House majority since World War I—to force Pelosi to guarantee a floor vote on Medicare for All. On the other side are Ocasio-Cortez and a different set of leftist pundits and journalists. The fight has turned intense and bitterly personal—the kind of thing that happens when a movement has been knocked back and has to pick itself up again.

The proponents of a floor vote have a lot of understandable frustrations and some valid arguments. But, for reasons I’ll get into, a floor vote ultimately isn’t worth it right now. That naturally raises the question: if not now, when? And more importantly, how does the left put itself in a position to actually come out of it looking like it has its shit together and can be a powerful force for progress in America? Luckily, there are two recent models for organizing around healthcare legislation to look toward: the 2009 Tea Party opposition to the Affordable Care Act, and the 2017/2018 left-liberal opposition to repealing it.

First, let’s look at the arguments for a floor vote. Writing in Current Affairs last week, Gray pointed to the recent bill to decriminalize cannabis, and argued that a floor vote on the bill would effectively relaunch the national dialogue about single-payer at a time when it’s never been more necessary to do so:

Just a week ago, the passage of the House bill decriminalizing marijuana was covered widely as “historic,”—perhaps because, like Medicare for All, it’s an enormously popular policy with bi-partisan support. (It’s also unlikely to pass the Senate.) And that was without the added drama of the most powerful Democrat in the House being bent over the proverbial barrel by a squad of progressive upstarts.

Gray is absolutely right that if the left wing of the caucus wants its votes to not be taken for granted for the next two years, a show of force that they can bend Pelosi to their will is important. As economist Matt Stoller has said, there’s a “culture of deference” to Pelosi within the caucus and the Democratic Party that is unrivaled by anyone alive, with the possible exception of Barack Obama. Feckless conservative Democrats have been the only ones to challenge Pelosi’s leadership over the past two decades and were crushed every time, while progressives have been content enough with her to pick other battles. And if the left doesn’t square up to Pelosi now, they may become even more marginalized in the future. Ocasio-Cortez recently argued in an interview with The Intercept, with a lot of evidence, that the people behind Pelosi—Steny Hoyer, Jim Clyburn, and especially heir-apparent Hakeem Jeffries—are even more hostile to progressives than Pelosi herself.

While Ocasio-Cortez has also argued that the left could use its leverage in the Speaker vote in more effective ways, pretty much all of the attempts at using that leverage have not worked so far. The progressives didn’t put up an alternative when they had a chance to during the caucus vote, so the only alternative to Pelosi is QAnon-friendly Republican Kevin McCarthy. Progressives including Ocasio-Cortez were locked out of the most powerful congressional committees again; Ocasio-Cortez was allegedly snubbed from the Energy and Commerce Committee because of her Pelosi criticism, but multiple reports have made it clear that she was also punished for supporting primary challenges to other Democrats, including Republican-endorsing Rep. Henry Cuellar. (Alex Sammons’ recent American Prospect report on the obscure steering committee vote that led to Ocasio-Cortez’s exclusion is required reading for anyone who wants to understand how the Democratic center wields power to try to force the left to fall in line; to her credit, Ocasio-Cortez has doubled down.)

It’s also clear that some of the ideas for using leverage are a bit stale. In addition to talking about “elevating longtime progressive champions” to leadership just days before she got shanked by the right in the E&C vote, Ocasio-Cortez recently floated a $15 minimum wage in the first hundred days, which isn’t exactly up to the House, as they already passed that in this Congress and it wasn’t taken up by the Senate. (If they win the Senate after the Georgia runoffs next month, Joe Manchin will decide the fate of a $15 minimum wage.)

Any leverage used would be pure symbolism at this point, but symbolism is important, especially when progressives want to show that they’re not “junior partners in the coalition” but rather an independent, influential force in American politics. So getting a big vote on something that is tied to progressives, which most House Democrats at least claim to support, and that has some actual resonance with the public in a way legislative procedure won’t, would be the most useful concession to draw here. Forcing a vote on legalizing cannabis, a minimum wage attached to inflation, abolishing the federal death penalty, and/or $2,000 monthly checks are all things that would put Democrats on the spot and show that progressives can steer the agenda in a Biden presidency in the way the left is looking for.

What doesn’t help and might in fact hurt is a crushing defeat for Medicare for All, which would be a very real possibility if this vote were to be held in Biden’s first hundred days. Gray cites the issue of marijuana decriminalization, but unlike Medicare for All, that was supported by nearly everyone in the Democratic caucus and even a few Republicans. Medicare for All was only cosponsored by half the Democratic caucus in this Congress, and in the next one, there will be a Democratic president who explicitly opposes Medicare for All and has promised to veto it. If every single cosponsor voted for it and everyone who isn’t cosponsoring voted against it, it would still be defeated by just under 200 votes, but that’s unfortunately an optimistic estimate. You only need to look at the roster of Democratic primary candidates to get a sense of just how committed a lot of these people are to the goal of single-payer.

Vice President-elect Kamala Harris, Sens. Elizabeth Warren and Cory Booker, and Rep. Tim Ryan have all been cosponsors of the Medicare for All bill in either this Congress or the last one. The first three released their own healthcare plans that aren’t Medicare for All, just called that. And after putting his name on this year’s Medicare for All bill as an original cosponsor in February, just five months later Ryan took what will likely ever be his only notable appearance on a national stage and used it to argue that single-payer would be bad for unions, because apparently unions should like having more things to negotiate for in contracts.

In addition, this sets the expectation that House Democrats would begin their agenda in the next Congress by embracing a healthcare policy which their own incoming president not only explicitly rejected but heavily implied he would veto if it were to hit his desk. That would never happen. If you think the Republican Party’s kid gloves treatment of Trump was bad, the way most congressional Democrats handle Biden will not look much different.

There’s no obligation for anyone to consider what an embrace of Medicare for All would do to Joe Biden’s political capital to be a real reason for voting against it. But most mainstream Democrats are not itching for that fight with the leaders of their own party right now, not least because they know it would ultimately fail once it hits the Senate. This is only a move you pull when you know you have a good chance of winning the fight.

The floor vote supporters argue that it’s ultimately more important to push the issue now, since even if the vote fails miserably, it’ll force both squishy cosponsors and opponents of Medicare for All to commit to a vote on the record, and that this would both make sure the “yes” votes are actually yes votes, and expose the “no” votes as obstacles worth primarying.

In some ways, this is an enticing prospect, as there’s a risk in having fairweather friends when opponents of Medicare for All already have an enormous advantage. But there is also a risk in pushing the best members of Congress out into a fight they cannot possibly win—one that, far from showing the strength of the Medicare for All coalition, could make them look as isolated and weak as ever, and could give the Democratic leadership the perfect excuse to never let another Medicare for All vote see the light of day for the foreseeable future.

What’s more is that we already know who’s most worth primarying, because for years Medicare for All has existed as a messaging bill where the left has openly courted cosponsorship as support. If there’s any chance at all that a vote will be an embarrassment for advocates, we should stick with cosponsorship as the barometer until the numbers improve.

Over the past two cycles, there’s been no evidence that Medicare for All support has made the difference in the most successful and near-successful primary attempts. With the exception of Rep. Dan Lipinski, an anti-choice nepotism case who thought even the Affordable Care Act was too left-wing to vote for in 2010, every single Democratic member who’s been successfully primaried out of a job—Reps. Joe Crowley and Michael Capuano in 2018, and Reps. Eliot Engel and Lacy Clay this year—were also Medicare for All cosponsors when they lost renomination.

These primary wins are important; just saying you’ll vote for something is different than making the public case for it on a regular basis, and Ocasio-Cortez and Cori Bush are much more committed than Crowley and Clay were. But more often than not, legislators are being kicked out of office less because of their positions on left-wing priorities than because they no longer reflect the district’s values or its demographics or they’re just straight-up ignoring their constituents.

Later on in her piece, Gray makes an important point about using the pandemic to point out the flaws of the healthcare system:

Mass unemployment and the subsequent loss of employer-based coverage has stripped corporate Democrats of one of their most potent arguments against Medicare for All: that maintaining the for-profit health system offers much-desired stability. And commitments to cover COVID-related costs have exposed the hypocrisy inherent in defenses of our current system. The admission by party leadership that COVID treatment should be free for all is a slippery slope to universal coverage. After all, it’s not more inhumane to deny COVID treatment to those who can’t pay for it than to deny treatment to a cancer patient who can’t pay. (Cancer is a primary cause of bankruptcy in America.) Should progressives force a floor vote, they’d be well positioned to make a relatively unencumbered case for Medicare for All.

I disagree that anti-Medicare for All Democrats can be convinced into supporting Medicare for All just because of the admission that treatment for COVID should be free. It’s not a glitch in logic that makes Democrats oppose Medicare for All while also supporting free treatment for COVID, it’s an ideological commitment to neoliberalism. As Chicago School economist Robert Lucas said as the global financial system was melting down in 2008: “I guess everyone’s a Keynesian in a foxhole.” Democrats will lose no sleep over the inherent contradictions in their beliefs, as people who can’t afford healthcare go without it while health insurance companies post multi-billion-dollar profit margins.

But Gray is right that there is absolutely no reason why COVID treatment should be free and cancer treatment shouldn’t. Millions of people, through personal experience or a loved one, are for the first time considering their own mortality while engaging with a healthcare system that is largely based on greed and brutality. Every single one of them is a potential convert to the cause of Medicare for All.

This is where what happened in 2009 and 2017 can be instructive. Though the demands in both cases were completely at odds with each other, the people involved hounded their members of Congress at town halls—just let them have it—over and over again. It wasn’t a chance for constructive dialogue between constituents and their elected representatives; it was an opportunity to berate them. It was a warning that if they didn’t vote the way their constituents wanted them to, their ass was basically gone the next time around. These groups made themselves look larger than they were by spreading out throughout the room, disrupted prepared talking points, ruined photo ops—basically whatever they could do to get more attention, to make their members feel as though they might actually face consequences for voting against the protesters’ position.

And it worked. The media was eventually forced to cover the protests and take their demands seriously. In the case of the Tea Party, they could not overcome the overwhelming Democratic majorities during the first two years of Barack Obama’s presidency to stop Obamacare, but they guaranteed unified Republican opposition to the bill and got dozens of Democrats to help water it down and then vote against it too, and then blew the Democrats out of the war in 2010. Liberals and progressives, for their part, both stopped the ACA repeal in 2017, and then took back control of the House in 2018 for just the third time since 1994.

It’s not a 1:1 comparison, of course. While you’ll see a case for Medicare for All in the op-ed pages of national papers every once in a while, the media has shown its hostility to Medicare for All is much more vicious than what Republicans screeching about death panels and killing grandma were dealing with in 2009. The Tea Party also had Koch money behind it, and the anti-ACA repeal effort had, for a brief moment, essentially everyone to the left of Mitt Romney pointing their disgust and more importantly negative energy at the same target. And elected officials have adapted over the years and begun avoiding town halls. Plus, there’s obviously a lack of in-person town halls right now.

But the outpouring of Zoom disgust at city councils and police across the country this summer during protests for racial justice proved the format is not totally useless for now, and if your representative won’t hold a town hall, they’re probably doing events in your district. Crash those! Flashy parliamentary tactics have their place, but what Medicare for All really needs is a sustained movement behind it.

And you don’t need to be funded by billionaires or in on strategy calls with the Democratic National Committee to get a few dozen people together to engage in the bonding experience of yelling at your congressman to actually do something useful for once. The DSA and other pro-Medicare for All groups have already succeeded in getting some skeptical members, like Reps. Lloyd Doggett in Texas and John Yarmuth in Louisville, to cosponsor the bill.

Transforming this groundwork into a coordinated national operation of hellraising should be a top priority as Medicare for All supporters both inside and outside of Congress navigate a completely different political environment. It’d be a stretch to insist that a floor vote held after nine months or a year and a half of consistent protests would pass, but it has a much better chance of getting substantial support than it would immediately after Biden takes office.

This is an important fight for the broad left to have, even if it’s resulted in some frankly wild personal attacks and speculation about secret motives on both sides. The left’s tactics should be confrontational, and even the most friendly politicians should be treated with a certain degree of suspicion. And Gray and Dore speak for a lot of well-intentioned, justifiably angry people who have seen left media—I include myself in this—celebrate the growing number of genuinely left-wing people in Congress, and then been disappointed by the fact that they’re still far too few in number and too low down the pecking order to facilitate the kind of big victories we elected them to win.

People are very understandably pissed to be forced into a defensive position again, especially at a time like this. But for right now we have to deal with the Congress we have and not the one we want, and put ourselves in a better position to get the one we want. This is not about acting like a meek supplicant in the Democratic caucus; it’s about targeting Pelosi and the leadership in ways that will actually wound them.

The shared end goal here is getting us closer to and eventually winning Medicare for All. Right now, the best way to do that is to focus on expanding its constituency both in the public and in Congress—not a high-risk, low-reward move that could leave us even worse off than where we started.