By Kay Tillow

Aug. 6, 2018

On July 13, 2018, in an article [1]  on Vox, Tim Higginbotham and Chris Middleman of the Democratic Socialists of America’s (DSA) Medicare for All campaign condemned Paul Krugman, Adam Green, the Center for American Progress, and Andy Slavitt for their efforts to co-opt and water down the “Medicare for All” slogan into meaningless vague principles and inadequate programs.  They are absolutely right!

Higginbotham and Middleman’s analysis of those who seek to use and abuse the growing popularity of “Medicare for All” while abandoning the struggle for a real national single payer program is excellent.  The door-to-door grass roots proposal of the DSA is compelling with its plan to reach into the heart of every community.

But there is a problem embedded in Higginbotham and Middleman’s core principles that threatens to destroy all of their good work and do damage to the robust and growing single payer movement.  Their five core demands which they assert “dovetail with the Sanders and Ellison bills” are inadequate to give us a viable single payer system.  Why are Higginbotham and Middleman moving the goal posts?  Their core demands are good—but too sparse to support the reform they say they seek.  And the Sanders Senate bill S 1804 [2]  and the Ellison House bill, HR 676 [3]are worlds apart.

Do Higginbotham and Middleman really want to leave long term care out of Medicare for All?  Their principles do not include it.  That would abandon this vital care to the state Medicaid programs that require impoverishment prior to entering a nursing home.  Leaving long term care to state Medicaid programs assures wide variations from state to state as some states will provide the sparsest of care.   Medicaid has means-testing for eligibility, and that will worsen economic inequality as families must spend a lifetime of assets for final care.  This will worsen the wealth gap because nothing is left to be passed on to families.   Long term care isn’t included in Higginbotham and Middleman’s core demands even though it is a part of HR 676.  It is a necessity and should be included.  All necessary care for everyone means something.  Don’t dilute it.  The Senate bill S 1804 also excludes long term care.

Do Higginbotham and Middleman really want to allow the investor-owned, for-profit hospitals and nursing homes to continue to gouge patients with their higher costs and higher mortality rates?  In their article they call for the elimination of the profit motive, but their core principles are silent on this vital issue.  Does not removing the profiteers merit inclusion?  HR 676 transforms the investor-owned, for-profit hospitals, nursing homes, and other institutions.  S. 1804, the Senate bill, does not.  Shouldn’t ending the profits in health care be a core demand?

Check out the research.

“It has been shown that patients cared for at private for-profit hospitals have higher risk-adjusted mortality rates than those cared for at private not-for-profit hospitals[4].”


Private for-profit hospitals result in higherpayments for care than private not-for-profit hospitals. Evidence strongly supports a policy of not-for-profit health care delivery at the hospital level.[5]”

Removing the for-profit hospitals and nursing homes must be a core demand.  As Dr. Andy Coates puts it,

“…it’s appalling that one person’s illness would be an opportunity for another to make money. The care of human beings should not be a commodity[6].

The United States spends over twice as much on health care, per capita, as the average of other industrialized countries that provide universal health care.  So reaching our goal does not require spending more, but instead saving by removing the insurance companies and eliminating the waste caused by profits.  Improved Medicare for All, a national single payer system, requires administrative savings to free funds to improve care for all and expand it to everyone.  Yet Higginbotham and Middleman leave out of their core principles the vital global budgeting of hospitals and nursing homes and the separation of construction from operating costs.  These are essential to assure the savings to make single payer financially viable.  Is this not a core principle?

Without global budgets, the national system has little power to constrain long-term costgrowth.” [7]

In January of 1989 the Physicians’ Proposal for a National Health Program8 was published in the New England Journal of Medicine.  Through updates in 2003 in the Journal of the American Medical Association7 and in 2016 in the American Journal of Public Health[9], the plan of Physicians for a National Health Program (PNHP) has continued as the evidence-based single payer proposal uniting a national single payer movement.

In 2003, with the assistance of the Physicians for a National Health Program, Congressman John Conyers, Jr. of Michigan put this plan into legislative form and introduced it into the House of Representatives.  Conyers introduced this bill, HR 676, into every Congress since that time, and it has been the sound legislation, Expanded and Improved Medicare for All, that now has 123 cosponsors.

When Rep. John Conyers resigned, Rep. Keith Ellison took over the lead sponsorship of HR 676.  He, too, will be leaving the Congress to run for attorney general for the state of Minnesota.  Nothing is more important than that the new chief sponsor, whoever that may be, be willing to maintain HR 676 as the model plan, based on the PNHP proposal, that when enacted will bring us the universal care we need.

Some have suggested that the model single payer bill, HR 676, needs to be rewritten to conform to the flawed senate bill S. 1804.  That would be a disastrous setback for the single payer movement.  S. 1804 excludes long term care.  S. 1804 maintains private, for-profit hospitals and nursing homes.  S. 1804 includes some copayments for drugs.  S. 1804 has no global budgeting of hospitals.  S. 1804 adopts in Section 611 (b) a “value based payment” system that has been proven to discriminate[10] against physicians who care for those with low incomes.  S. 1804 has a public option[11] and a Medicare buy-in [12] that will become barriers to achieving single payer.  S. 1804 needs to be improved to come up to the standards of HR 676.

As every trade unionist knows, a compromise placed on the bargaining table at the beginning of negotiations becomes a ceiling above which it is not possible to go.  If the ceiling is below viability of the new system, the plan fails before it gets off the ground.  It is vital to set the standards high.  A watered down, puny reform cannot inspire a nation to fight for it.  We need a bold and beautiful plan.

So applaud Higginbotham and Middleman’s grass roots campaign.  Join in the knocking on doors.

Build and energize across the country.  But don’t dilute the single payer principles.  Improved Medicare for All means something!

This article first appeared in the Daily Kos.