When she ponders U.S. healthcare, Democratic Rep. Debbie Dingell thinks about how the automakers of her native Detroit had to become "healthcare providers who happened to make cars."
She thinks a lot about employer insurance, the unwieldy bedrock of the American system. She knows all about it from her decades of working for the Michigan auto industry and—most recently—from navigating hospitals during late husband and legendary congressman John Dingell's illness.
And this has framed her approach to the single payer issue that has driven the Dingell family for past 70 years: grappling with what's next for employer insurance when costs are rising for everyone involved.
"People are getting mad that they think their health insurance is getting taken away," Dingell said in an interview earlier this month at her office on Capitol Hill. "But the bigger crisis is that companies can't afford to provide health insurance anymore."
Dingell is the lead co-sponsor on the latest House Medicare for All or single-payer bill, introduced earlier this year by progressive Democratic Rep. Pramila Jayapal of Washington. On Tuesday, the bill will get its first hearing in the House Rules Committee. Last summer, the two launched the Medicare for All Caucus.
For many, Jayapal in the House and Vermont progressive independent Sen. Bernie Sanders in the Senate are the congressional faces of single payer.
But Dingell is a quiet factor, someone who represents the trajectory in U.S. health policy since World War II as she carries the Dingell legacy.
She is also beloved by her Republican and Democratic colleagues as a practical bridge-builder, as well as a relentless advocate for issues that matter to her. And, perhaps most crucial of all, she has a deeply personal stake in the debate's outcome.
Her husband of 40 years, as the longtime, powerful chair of the Energy and Commerce Committee, fought for decades for a single-payer system. And he carried the flame from his father, John Dingell Sr., who helped pass Social Security and took the lead on the House side for a single payer bill in 1943.
Before her husband died, he asked her to take it the rest of the way. And she promised she would.
"It was something he had worked on his whole life, and we had been at the doctor and someone had talked to us about being afraid of—this happened a lot—pre-existing conditions, and he said, 'Deborah, you can't stop working on this; you've got to get it done.' "
The political forces of today's landscape aren't all that different from what they were in 1943, when—before she was born—her future father-in-law joined Sens. Robert Wagner (D-N.Y.) and James Murray (D-Mont.) on a national health insurance bill known as the Wagner-Murray-Dingell Act.
But the employer market was just beginning. That very same year, 1943, the Internal Revenue Service created the tax exemption for employer insurance at the behest of unions. Meant to be temporary, the exclusion would form the system that's now in political crosshairs.
Employer insurance covers most Americans, but it's had a rocky road for decades. And recently it's grown more expensive for employers, even as they offload more of the cost to their employees through high deductibles and co-pays.
Politically, both sides bemoan cost because they have to. Healthcare is on its way to account for $1 out of every $5 spent in the U.S. And industry lobbyists in the 2018 election cycle spent nearly $561 million, according to an analysis of disclosures by the Center for Responsive Politics.
Dissatisfaction with healthcare costs has fed public momentum for the newest push for Medicare for All, as hospitals, insurers and pharmaceutical companies and groups band together to lobby Congress and the public.
But even though the dollars have swelled and the fight against single payer has grown more sophisticated, the opposition is following an old playbook. Industry is credited with tanking the early push for universal coverage throughout Franklin Roosevelt's New Deal years—with the American Medical Association and the American Hospital Association taking a hard line against it.
The AMA's stance spurred Sen. Robert Wagner to write a letter to the Journal of the AMA.
"I hope that you will print this letter in the Journal and that you will join me in urging the medical profession to undertake an earnest study of the actual provisions of the bill," Wagner wrote in June 1945. "In this way you can help immeasurably in avoiding misunderstanding and misinterpretation of the legislation and in stimulating physicians and medical and hospital organizations to come forward with constructive suggestions and advice."
In the national health insurance bill co-led by Dingell Sr. in the 81st Congress (1949-1950), the statement of purpose described familiar issues: "the inability of the vast majority of our people to meet the shattering cost of serious or chronic illness," and a "serious maldistribution of both personnel and facilities, so that some areas are disproportionately supplied in relation to others which suffer from an almost total lack of decent medical care."
That preamble echoes the stories Debbie Dingell continues to gather from people she knows and from constituents: from the group of Dearborn friends she meets for coffee who describe how they break up their insulin pills to be able to afford them; or "the farmer whose child had a cold and they couldn't afford to go to a doctor and it turned out to be pneumonia." As an advocate for breast cancer treatment she tells women to get a mammogram and hears: "But if you need treatment, how do you pay for it?"
Dingell reminds people that while her husband didn't see universal coverage, he still worked through the decades and helped pass Medicaid, Medicare, the Children's Health Insurance Program, establishment of the National Institutes of Health and the ACA.
So she's patient, she said, and willing to trot across the country to work at getting buy-in. Like her husband, willing to roll up her sleeves on the incremental issues while keeping a goal in mind.
Her longtime friend Rep. Fred Upton, the Michigan Republican who also once chaired Energy and Commerce, said Debbie Dingell knows how to get things done. And he especially noted her ability to work with both parties, although he does not support her legislative efforts to pass Medicare for All. He said she has already made a mark on the same committee her husband used to run.
"She was a mainstay in John's life, and John's life is now over, but she's a part of that ripple that's not going away, of the things that he cared about that she has a passion for as well," Upton said.
And she's determined, he added.
"When she speaks, people will listen because she doesn't take no for an answer. People who know her well can needle her and always elicit a smile—and a focus on substance and policy."
For the long haul, that focus is trained on universal healthcare, with the reminder to everyone that it's "a competitive issue for us in this country."
"I want to bring all the stakeholders to the table," she added.
