Despite the federal government shutdown, the struggle over the future of health care is reaching a fever pitch in Washington and in several state capitols. The beginning of the legislation season has kicked off a period in which social movements, organized labor, health care workers, health care industries, chambers of commerce, think tanks, and politicians are all competing to assert their power and advance their visions for the future of health care.

This fervor comes despite that fact that no federal health care legislation and very little significant state legislation is likely to pass this spring. Instead, most of what will transpire is a struggle for positioning heading into the 2020 election, when the future of health care will really begin to take shape. Though the struggle will not be led by mainstream Democratic Party leaders (both major parties are weak by historic standards), it will be nevertheless be mediated through the Democratic primaries and general election as competing forces all vie to gain the upper hand in shaping the public discourse and setting policy.

For the human right to health care movements for a universal, publicly financed health care system, this is a critical time to build power and make sure that public debates and proposed legislation meet human rights standards rather than perpetuate today’s inequitable and undemocratic profit-driven system. Here are the key bills and policy struggles we expect to see over the next six months.

U.S. House bills on national ‘Medicare for All’ and state-based universal health care

Representative Pramila Jayapal, Chair of the House Progressive Caucus, will introduce a new bill for a national, universal, publicly financed, improved ‘Medicare for All’ program in the coming weeks. The bill will cover comprehensive health care including primary care, hospital and outpatient services, prescription drugs, dental, vision, audiology, full reproductive health services including abortion, maternity and newborn care, long-term care services and supports, mental health and substance abuse treatment, laboratory and diagnostic services, ambulatory services and more. It will also eliminate premiums, co-pays, and deductibles, all of which are key barriers to care.

A coalition of Medicare for All supporters including Healthcare NOW!, the Labor Campaign for Single Payer Healthcare, National Nurses United, Physicians for a National Health Program, and Public Citizen is working with Rep. Jayapal to shape the bill.

Rep. Jayapal and the Progressive Caucus have succeeded in pressing Speaker Nancy Pelosi and the Democratic leadership to allow hearings on the bill to proceed in two committees, the Rules and Budget committees, but Politico reports that top Democrats will not let the bill get to a vote on the House floor. To build energy around the bill, the coalition partners are organizing a week of action February 9-13.

Meanwhile powerful and well-financed corporate interests led by the insurance, drug, and hospital industries have launched a lobbying group, the Partnership for America’s Health Care Future. The Partnership is using highly misleading scare tactics to raise public alarm about how Medicare for All would transform the health care system and is working behind the scenes to peel off would-be coalition supporters by using age-old divide-and-conquer tactics.

In addition, Rep. Jayapal may re-introduce the State-Based Universal Health Care Act (HR 6097), which she originally introduced last year. Support for the bill could be an important complement to support for Medicare for All. Should Medicare for All fail to overcome corporate and ideological opposition by 2021, the focus of movement building and health care reform could return to the states.

New York Health Act

The Campaign for New York Health has passed the New York Health Act through the Assembly two years in a row, and last year came just one vote shy in the Senate. The Act would create a statewide universal, publicly financed health care system in New York.

In November, New Yorkers elected a progressive-led Democratic majority to the State Senate, opening up a real possibility that the bill could pass both houses this spring and land on the desk of Governor Andrew Cuomo to either sign or veto. Though Governor Cuomo has not said explicitly what he would do, he has never supported the bill, and most observers predict he would either veto the bill or bargain with enough legislators to vote against the bill in order to keep it from getting to his desk in the first place.

The real possibility that the Act could pass has, not surprisingly, aroused major opposition. The insurance, pharmaceutical, and hospital industries and their backers have banded together to launch a lobbying group, Realities of Single Payer, that is provoking public fears about universal health care and, like Governor Cuomo, peeling off supporters by offering money and support for other priorities.

The effects of these divide-and-conquer tactics have been most visible in a contentious struggle that has arisen within the labor movement over the bill. As Gothamist and Politico explain, the New York State Nurses Association and other health care worker unions are supporting the bill, teachers unions are so far remaining neutral, municipal employee unions are publicly questioning the legislation in order to extract concessions, and the construction trades are actively working against it.

NYC Care

New York City Mayor Bill DeBlasio announced NYC Care, a major new city-level program for providing universal, publicly financed health care to uninsured residents, specifically including undocumented residents who have been unjustly denied access to Medicaid, insurance subsidies, and other programs under federal and state law. NYC Care is modeled on Healthy San Francisco, which was launched by the City of San Francisco in 2007 and, at its peak, provided health care access to one in six residents. NYC Care will directly pay for primary care for uninsured residents and will also provide public insurance to cover residents’ medications, mental health services, and hospital expenses. The program will begin operating later this year.

In addition to directly meeting the health care needs of hundreds of thousands of residents, Healthy San Francisco and NYC Care provide a successful model for other cities and counties, and help debunk the common narratives that it is unaffordable, impractical, or politically unpopular to publicly finance health care.

California

On his first day in office, Governor Gavin Newsom made health care his biggest focus. He proposed several health care reforms, mostly incremental reforms to shore up and expand on the Affordable Care Act (Obamacare):

• creating a state insurance mandate to replace the federal one Congress removed,
• expanding ACA insurance subsidies to middle-income people,
• allowing undocumented immigrants between 19 and 25 to buy into Medicaid,
• requiring the state agency that oversees Medicaid to bargain drug prices,
• banning catastrophic insurance plans, and
• using behind-the-scenes measures to stabilize the insurance markets and keep costs down for “consumers” (reinsurance for insurers who lose a lot of money in a given year and expanding subsidies to insurance companies to allow them to pass through cost savings to “consumers”).

If achieved, these measures will improve health care access and affordability for hundreds of thousands of Californians, but they would not fundamentally alter the profit motives that drive health care companies to deny people care and drive up health care costs.

In addition to pursuing these measures, Governor Newsom continued to voice rhetorical support for universal, publicly financed health care in California—a key focus of his on the campaign trail. He submitted a letter to Congress and the White House asking for the White House to signal that it would be willing to allow states to allocate federal funds to a state-based universal health care program. Federal approval would be necessary for any state universal health care program to work. Nobody expects the Trump administration to approve such a request, so Newsom’s move was primarily symbolic. It remains to be seen how committed to passing universal health care he truly is.

A key lesson from the Vermont Workers’ Center’s Health Care Is a Human Right campaign for universal, publicly financed health care in Vermont is that politicians cannot be trusted to lead the way on transformative changes like universal health care that threaten private profits and power. Instead, popular movements must grow strong enough to hold politicians like Governor Newsom accountable and leave them no choice but to side with human rights struggles.

New Mexico

Two coalitions in New Mexico are working to pass major health care legislation this spring. The grassroots Health Security for New Mexicans Campaign is seeking to pass the Health Security Act to move the state toward a universal, publicly financed health care system. Meanwhile New Mexico Together for Healthcare is pushing a bill to allow state residents whose income exceeds the Medicaid eligibility threshold to enroll in Medicaid by paying monthly premiums.

From a human rights perspective, a buy-in option is a mixed bag. On the one hand, it would make affordable health care more accessible to a slice of middle-income residents who are squeezed out of the existing health insurance system, and it would bring people into the state’s public Medicaid program instead of funneling people toward private insurance companies. It has also been argued that a buy-in could move us toward a fully universal, publicly financed system over time by setting up a dynamic in which more and more people decide to shift from private insurance plans into the public option until eventually private health insurance whithers away. On the other hand, charging people premiums in order to enroll in Medicaid could set a dangerous precedent by shifting the program from public toward private financing and by making eligibility contingent on people’s ability to pay rather using tax financing to ensure that health care is provided as a public good for all. A buy-in would also leave intact the multi-payer insurance system that produces costly complexity for patients and medical providers, creates inequitable tiers of health care access, allows profit-driven insurance companies to restrict patients’ coverage and care, hijacks our political system through campaign financing and lobbying, and shifts key decision-making about our health care system from the democratic sphere to corporate board rooms and executive suites.

Medicaid

The final key front in health care politics this spring is Medicaid.

On the positive side, Medicaid expansion is being implemented in at least three states: Idaho, Maine, and Nebraska. These expansions will expand health care access to hundreds of thousands of uninsured poor and working class, a major human rights victory. Voters in a fourth state, Utah, also approved Medicaid expansion in the November election, but lawmakers are attempting to block people from enrolling, leaving the efficacy of the expansion in doubt.

Meanwhile 15 states are continuing to pursue and implement work requirements and other onerous measures that are designed to push people off of Medicaid. The Trump administration has already allowed seven states to require Medicaid enrollees to repeatedly submit onerous paperwork detailing their employment, work hours, and/or job-hunting activities. These are burdens that middle- and upper-income people are not required to endure, and because they are so hard to complete, their chief effect is to make working people ineligible for continued coverage. Last year Arkansas became the first state to implement work requirements in Medicaid, and in a matter of months, lawmakers have already stripped 18,000 of Medicaid eligibility.

One bright spot is Maine, where newly elected Governor Janet Mills, facing pressure from the Southern Maine Workers’ Center, Maine Equal Justice Partners, and other organizations, sent a letter to the Trump administration rejecting the punitive requirements proposed by her predecessor, Governor Paul LePage. This move, combined with Maine’s Medicaid expansion, will greatly expand health care access to residents.