For almost 15 years, Pramila Jayapal was an activist and organiser, working to change the system from the outside.
Now she is part of that system, seeking to secure what would represent one of the most seismic shifts in American society. The US is the only nation in the developed world without universal healthcare; a bill she introduced in February would change that, and provide care for all Americans via Medicare, a national insurance programme established in 1966 but which is currently only available, in the main, to those aged 65 and older (younger people with certain disabilities and people with end-stage renal disease also qualify).
Polls indicate considerable public support for her plan. But she faces massive, organised opposition from the private healthcare industry, which is lobbying to stop her bill and retain its profits, as well as conservatives who claim she is trying to bring so-called socialised medicine to a system that has long been permitted to run wild.
“We have a system that is designed around profit instead of patient care,” she tells The Independent in her congressional office in Seattle. “We have a system that has been cobbled together, but it’s controlled and driven by for-profit industries … and that means it doesn’t function for regular Americans.”
Jayapal was only elected to congress in 2016, the first Indian-American woman to join the House of Representatives, but has quickly emerged as one of its most high-profile progressives. She co-chairs the Democratic Party’s progressive caucus, which has around 100 members, supports the impeachment of Donald Trump, and acts as something of a mentor to progressives elected even more recently, such as Alexandria Ocasio-Cortez, Ayanna Pressley and Ilhan Omar.
America’s private healthcare system is notoriously vast, expensive and inefficient. Around $3.5 trillion (£2.8 trillion) is spent every year on a network of private hospitals supported by insurance policies, only some of which are provided by employers. For all of this money, 30 per cent of which is spent on administrative costs, results are patchy. For decades, for instance, the US’s infant mortality rate was higher than that of Cuba. Campaigners say 30 million Americans have no insurance whatsoever, and a further 40 million cannot afford the co-pays and deductibles, those elements people have to pay even if they have insurance.
Jayapal says Teddy Roosevelt first talked of universal healthcare in 1912 – “for which he was called a socialist”. A bill to introduce such a scheme was first introduced in the house by John Conyers in 2003, while Bernie Sanders, who made “Medicare for All” part of his presidential campaign in 2016, introduced a bill in the Senate in 2017, with an updated version this spring. Jayapal, 53, says her bill is more comprehensive, because it includes items such as long-term nursing coverage, which Sanders’ does not.
Under her plan, Americans would receive care from a single, government-run scheme that covered all costs and did not require them to contribute co-pays. As Vox put it, it would include hospital visits, primary care, medical devices, lab services, maternity care and prescription drugs. It would also stretch to include optician and dental benefits. Somewhat controversially, it would prevent employers from offering separate schemes that compete with the government-run plan. People could still choose whatever hospital or doctor they wished to make use of. It would also include provision to help people employed by private insurance firms who lose their jobs in the transition to a single-payer system.
Polls show a majority of Americans, perhaps up to 71 per cent, support the idea, especially if it did not involve higher taxes or waiting times, and guaranteed health insurance as a right. If the scheme called for higher taxes, support falls to 37 per cent, according to a Kaiser Family Foundation poll released in January.
While Jayapal’s legislation does not yet include a specific funding proposal, Sanders’ proposal has been estimated to cost $32 trillion over 10 years. He has outlined a way to pay for that with progressive tax increases, including a marginal tax rate of up to 70 per cent on those making above $10m a year. She says a white paper costing the legislation will likely be released when it is introduced on the floor of the house.
Jayapal says public opinion has shifted in her favour, a move she credits to the passage of Barack Obama’s Affordable Care Act (ACA), his landmark 2010 overhaul of the healthcare system that ensured at least 20 million additional people had health insurance, and the stunning momentum of Sanders’ 2016 presidential run.
“People started to change the way they thought about healthcare in their life. It became a right and not a privilege,” she says. “In addition, when the Republicans started stripping healthcare away, it set up this contrast.”
She faces a huge fight. A coalition of health industry players and lobbyists, calling itself the Partnership for America’s Health Care Future, is utilising vast sums to persuade people Jayapal’s plan would lead to longer waiting times to see a doctor, increase taxes and reduce individual choice. The group spent $143m in 2018 on adverts attacking Medicare for All, adverts Sanders said were a deceptive effort by “special interests that continue to reap hundreds of billions of dollars” from the status quo.
Meanwhile, the Coalition Against Socialised Medicine, a network of conservative groups, has come together to oppose what it claims, without providing evidence, are policies that have “failed in Europe”.
“It is critical to America’s patients, taxpayers and economy that members of congress stand up to prevent the further government takeover of America’s healthcare markets and join us in our efforts to defeat these radical proposals,” Matt Schlapp, chair of the American Conservative Union, said this month.
Asked how she intends to defeat such powerful opposition, Jayapal says she is relying on “people power”.
“They have tens of millions of dollars. We are never going to be able to put in the money these pharmaceutical companies and drugs companies and for-profit insurance companies are putting in,” she says.
“But we have people And the thing is, everybody has a healthcare story. You know, one in five families cannot afford prescriptions, families sit at their kitchen tables cutting their prescription drugs in half. People are using GoFundMe as their major insurance plan.”
Jayapal, whose family moved to the US when she was 16, is a member of the house judiciary committee, and has called for the impeachment of the president. The Democratic-controlled committee’s desire to launch such proceedings, something backed by many progressives, has so far been held back by Nancy Pelosi, who believes impeachment would distract from the 2020 election and energise Trump’s supporters. Many think Pelosi, the 79-year-old house speaker, who last week said she would like to see the president “in prison” after he leaves office, is out of touch and failing in her constitutional duties.
Jayapal says she does not share that perspective. “Not everybody is where I am. More and more people are coming to that same conclusion, but it’s her job to corral the whole caucus,” she says. “If you look carefully at her language, it has changed substantially. Even last week it changed. She has called him a criminal. She has said he has committed crimes.”
In 2016, Jayapal endorsed Sanders for president, and he backed her house run. She refuses to discuss whether the Vermont senator would have defeated Trump had he been the Democratic candidate, or if Hillary Clinton erred tactically by failing to name him her vice-presidential running mate.
This cycle she has not yet backed a candidate, but says she has been impressed by the consistent boldness of Sanders and Elizabeth Warren. She says Kamala Harris and Jay Inslee have also been leading the field in their own platforms. Asked if it was not ridiculous the party’s two leading candidates to replace 73-year-old Trump, were 77-year-old Sanders and Joe Biden, who is 76, she says she is frustrated women rarely get the same attention as men when they run for office.
In what may have been an attack on Biden, who is among only a few 2020 candidates to have accepted campaign money from large, corporate donors and who has been criticised over policy positions out touch with many progressives, she says she wants a candidate who is going to “take on the deep inequity and inequality that exists in America today on every single level”.
“And it’s got to be someone who can stand up to the special interests and can’t be beholden to the same interests we’re in today,” she adds.
Asked the chances of Trump being re-elected, she says she was among those who thought he could win in 2016 “because racism and sexism and xenophobia and homophobia are very potent organising tools”.
“Part of why I have always thought organising is so important is because in the end you have to change the electorate ... you have to change the people who vote,” she says.
“Anyone who thinks we’re going to win in 2020 either in the house, the Senate or the presidency, by only appealing to the swing voters, is missing the point of the 2016 and 2018 elections.”
She says Obama had been able to put together a coalition of supporters by appealing to young people, people of colour and women, many whom had never voted before. She says it remains to be seen if the Democrats’ 2020 presidential candidate can do that.
“We have to focus on a bold candidate who can mobilise, inspire and call forward people who have not traditionally been in the electorate, and people willing take on the status quo,” she says.
“We have the worst inequality in this country since the 1920s. Three people in the United States of America – two of whom live in my state – have the same wealth as 160 million Americans. We have got to take that on, because that is what led to Trumpism. Trumpism didn’t just come with Trump.”