Pathways to Winning Medicare for All
There are two basic ways that laws become enacted in Massachusetts:
• By a vote of the legislature.
• By an Initiative Petition placed on the ballot by the people and voted statewide in a general election held in even-numbered years.
Mass-Care's position is that while both paths present opportunities and difficulties, neither path can succeed unless a massive statewide grassroots organization is built. This organization must be based upon the broadest possible basis of all people, Black, white, Latino, Asian, Native American who are affected by the high cost and in many places the inaccessibility of health care.
There are no shortcuts to this basic organizing approach.
The Difficulty of Passing a Bill Through the State Legislature
The structure of the Massachusetts legislature is in many ways profoundly undemocratic. The Speaker of the House holds incredible power over elected legislators (power to appoint to committees, power to appoint to positions of leadership in committees, which provide extra income to elected legislators). Powerful legislators are beholden to even more powerful entities actively fighting reform, including for-profit health insurance, pharmaceutical, and finance companies which aggressively lobby and donate substantial amounts to the Massachusetts Democratic Party.
These factors have led to the Medicare for All bill never making it out of the committee (currently the Health Care Finance committee) where it has died every two years for the past 25 years that Mass-Care and allies have filed and lobbied for the bill.
The Difficulty of Passing a Bill Through a Binding Ballot Question
To get a proposed law on the state-wide ballot, first signatures of registered voters must be collected. A minimum of approximately 80,000 signatures are needed. In reality that means collecting 160,000 signatures because of the many that will end up disqualified (illegible signatures, residency/voter registration requirements, etc.). If enough signatures are collected and certified, then the State Legislature votes yea or nay on the proposed law. If the Legislature votes no, then an additional 14,000 signatures (28,000) must be collected. If they are certified, then the law will appear on the state-wide ballot.
An organization with significant capacity is needed to collect the signatures, which must be collected throughout the entire state (no more than 25% can come from any single county). This is just the first step.
Without a powerful organization that can threaten credible consequences to rogue legislators, the legislature can work to subvert or overturn the ballot question. In 1998, after voters approved a "Clean Elections Fund," the legislature at first refused to fund it and then voted to overturn the law. In 2006, the legislature refused to take the second vote on the Right to Health Care constitutional amendment and the Supreme Judicial Court refused to force them.
Finally, industry opposition will be fierce whether we try through the ballot or the legislature; but the timeline and urgency of the ballot invites a unique crush of spending that intensifies as election day approaches. If you haven’t inoculated the constituency to these attacks, the opposition can quickly decimate popular support.
This is one of the advantages of the legislative route: built-in stress tests. If you have pushed a majority of the legislature onto a bill, you have already done the essential work of organizing a deep and wide enough swath of the population to face industry attacks with resiliency. The ballot may be the vehicle to get Medicare for All over the finish line, but the organizing will still be necessary.
CASE STUDY: The Safe Staffing Ballot Question
In 2018 the Massachusetts Nurses Association, frustrated by years of trying to negotiate safe staffing ratios and by the refusal of the Legislature to address this issue, took their cause to the ballot. In the beginning the polls showed it had the support of the majority of voters in Massachusetts. As the election grew close, the hospitals in Massachusetts began to campaign against the proposal with TV and newspaper ads all proclaiming that if the question passed it would cause hospitals to close. In all, the hospital industry spent 25 million dollars on a massive fear campaign to oppose the question.
This was an unprecedented volume of money, and the campaign worked; voters overwhelmingly rejected the proposal. This was all to stop a rather small proposal that at most would have caused some hospitals to hire more nurses.
We can expect an even greater level of opposition from a ballot question threatening the very existence of profit-making health insurers. And of course it won’t just be the insurance companies but all privately-owned for-profit hospitals, drug companies, and medical equipment companies that have much to lose.
Mass-Care does not reject a binding ballot question; however, significant capacity will be required to win through the ballot as well. This is why we must build a massive grassroots movement to win, whether it's through the ballot or the legislature.
What Does Having Enough Power Look Like?
The ballot may well be a more likely path to single payer in Massachusetts; but many of the problems that plague us at the legislative route will still be with us at the ballot. The industry, the complacency of those with “good” health care, and the political machine will still pose serious obstacles.
The only way we’ll win is if we have deep and unshakable commitment from a crucial percentage of the state before the onslaught begins. This means building a grassroots movement in every district that is well-inoculated from the attacks and is willing to put boots on the ground to knock every door when the opposition throws the kitchen sink at us. Coincidentally this power can also be used to force our legislators onto the bill; that we don’t have a majority yet of legislators who are even willing to take the first step - cosponsorship of the bill - means we don’t actually have the broad and deep power we need to win at the ballot either.
Mass-Care is building such a network of organizations in Rep. districts that support and will work for the passage of Medicare for All in Massachusetts. Our goal is to have organizations in all of the State Representative districts to fight for whichever path opens to us.
That's a lot of work, but that is where our power resides.
Where Do We Stand Now?
Public support for Medicare for All has been rising due to ballooning insurance costs as well as the absurdity of employment-based health insurance in a pandemic-created mass unemployment crisis. In the political field, the Bernie Sanders campaigns brought the issue of Medicare for All to the fore, contributing to the rise in public support.
On the legislative front, the Medicare for All bills in 2021-2022 had a record 82 cosponsors in the House (41%) and Senate (43%); up from a record 73 cosponsors in 2019-2020. Since 2019, we've had a Medicare for All Caucus in the legislature, formed under the leadership of Rep. Lindsay Sabadosa and Sen. Jamie Eldridge.
Key unions are active members of the Mass-Care Coalition: Massachusetts Nurses Association, Massachusetts Teachers Association, American Federation of Teachers Massachusetts, UNITE HERE New England Joint Board, Service Employees Local 509, and others. Some of our coalition members are dedicated to fighting for Medicare for All, while others are multi-issue community organizations that see Medicare for All as a major issue. Winning Medicare for All will be a coalition effort and can not be done without not just the support, but also the active participation, of major workers groups.
We urge all people and organizations to join the Mass-Care Coalition and help us build the organization we need to win this important legislation.