By 2020 it was clear that Medicare for All would not pass a divided Congress. The political environment that the Partnership for America’s Health Care Future had spent two years and tens of millions of dollars constructing had done its work. The policy had majority public support. It did not have a path to a floor vote. The federal legislative window had closed.
A different kind of organization might have stood down. The threat had been contained. The immediate objective had been achieved.
PAHCF did not stand down. It redeployed.
The coalition that had spent $60 million opposing Medicare for All at the federal level shifted the weight of its operation to the states — to Colorado, Connecticut, Nevada, Washington, and every other state where reform advocates were attempting to create public healthcare options at the state level. The logic was consistent with the strategy documented in Articles 3 and 4: don’t wait for the fight to come to you. Go where the fight is going.
This is the operating model the organized interests side has refined over decades. It is not a campaign. It is a permanent operation that follows reform wherever it surfaces, at whatever level of government, with whatever resources the threat level requires.
Colorado: The Most Documented State Campaign
Colorado became the most thoroughly documented example of PAHCF’s state-level operation because the scale of its intervention was large enough to generate disclosure filings that made it visible.
In 2020 and 2021, Colorado was considering legislation that would have created a state public option — a government-run insurance plan that would compete with private insurers in the state marketplace. The proposal was estimated to save an average of 20 percent on premiums compared to equivalent private insurance plans available on the state exchanges. For Coloradans paying for their own coverage, that represented a substantial and concrete financial benefit.
PAHCF Action — the state arm of the coalition — spent more on lobbying in Colorado in 2021 than any other organization had spent in the state since 2011. According to reporting by Jacobin and Newsweek, the figure may represent the highest single-year lobbying expenditure by any organization in Colorado’s recorded history. The spending went toward television ads, mailers, and direct lobbying of state legislators.
The result was documented in the legislation itself. The actual public option component — the government-run insurance plan — was removed from the bill in an agreement made directly with the hospital industry. What remained after the industry’s intervention was a requirement that private insurers offer standardized health insurance plans and reduce premiums by 18 percent over three years. The public option, the structural reform that would have introduced genuine competition with private insurers, was gone.
The industry did not stop there. After successfully stripping the public option from the legislation, the coalition continued opposing the remaining bill — the one it had already substantially weakened. A Colorado state representative quoted by Jacobin captured the dynamic: “It’s a little intriguing to me that this is becoming such a big deal, because the bill is actually very narrow.” The industry’s continued opposition to a bill it had already gutted is not irrational. It is the continuous operations model functioning as designed — maintaining pressure not because the remaining legislation poses a serious threat, but because the habit of opposition, maintained continuously, shapes the environment for future reform efforts.
Connecticut: Dark Money and the Threat to Leave
Connecticut’s public option effort in 2021 produced a different but equally documented case study in the state-level operation.
The Connecticut Citizen Action Group reported that in the first six months of 2021, the insurance industry and its allies spent more than $1.3 million lobbying against legislation that would have created a public option for small businesses and nonprofit organizations. Of that total, more than $600,000 came from dark money organizations — including PAHCF Action — that do not disclose their funding sources.
The spending was accompanied by a direct threat. Five health insurance companies publicly warned Connecticut lawmakers that they would leave the state if the public option legislation passed. The threat to withdraw from the state market was not a lobbying argument. It was an economic ultimatum — comply with the industry’s position or face the disruption of the insurance market your constituents depend on.
The combination of dark money advertising, direct lobbying, and the explicit threat of market withdrawal represents the full toolkit of the state-level operation. Advertising shapes the public environment. Lobbying works legislators directly. The market withdrawal threat creates a concrete consequence that legislators must weigh against the reform’s benefits — a consequence that falls not on the industry but on the constituents the legislators represent.
This is the skin in the game asymmetry in operational form. The insurance companies threatening to leave Connecticut would leave their Connecticut operations behind. Their executives would not lose their health insurance. Their lobbyists would not lose their health insurance. The Connecticut residents who would lose access to their current coverage if the market disruption occurred would bear the cost of the threat. The people making the threat would not.
The Pattern Across States
Colorado and Connecticut are the most thoroughly documented cases because the scale of spending generated disclosure filings and because advocacy organizations tracked the campaigns closely enough to produce reports. They are not isolated examples.
PAHCF Action’s operations extended to Nevada, Washington state, and other states where public option legislation was being considered in the 2020 and 2021 period. The operational model was consistent: identify where reform was gaining momentum, deploy state-level lobbyists with established relationships in the state capitol, run advertising campaigns in local media markets, and apply direct pressure on key legislators in the relevant committees.
The state-level operation had an advantage the federal operation did not: state disclosure requirements vary enormously, and many states have weaker disclosure rules than the federal system. A coalition that is already operating as dark money at the federal level faces even less transparency pressure in many state environments. The full scope of PAHCF Action’s state-level spending across the 2020-2022 period is not publicly available in aggregate form. What is documented in Colorado and Connecticut is the floor of a larger operation whose full dimensions are not visible.
The Coronavirus Exception That Wasn’t
The Colorado campaign produced one specific documented detail that illuminates the operating logic of the coalition in terms that go beyond political strategy.
Colorado Governor Jared Polis declared a state of emergency over the spread of COVID-19 on March 10, 2020. PAHCF continued its spending on lobbying and public advocacy against the Colorado public option plan through at least March 17, 2020 — seven days into a declared public health emergency, during which millions of Coloradans were confronting the specific question of whether their healthcare coverage would be adequate to meet the crisis they were facing.
The spending did not pause for the emergency. State lobbying disclosure filings show $2.7 million paid to a media communications firm for broadcast, cable, and digital advertising during the first half of March 2020 — the period that included both the emergency declaration and the days immediately following it.
The decision to continue the campaign during a public health emergency is not documented as a strategic calculation in any available record. It does not need to be. It reflects the operating model: the operation runs continuously because continuous operation is what makes it effective. Pausing for a public health emergency would have been an anomaly in the model. The model did not pause.
What the State Strategy Reveals About the Federal Strategy
The shift from federal to state operations after 2020 reveals something about the federal strategy that the federal record alone does not make fully visible: the coalition’s objective was never specifically to defeat Medicare for All as a federal bill. Its objective was to prevent structural reform to the healthcare system — wherever that reform was attempted, at whatever level of government, in whatever legislative form.
Medicare for All was the highest-visibility version of that reform in the 2018-2020 period. The public option was a more modest version gaining traction in Democratic presidential campaigns. State-level public options were the incremental version being pursued where the federal environment was unfavorable. PAHCF opposed all three — not because its members had a specific objection to federal single-payer as opposed to state public options, but because all three threatened the same underlying financial interest: the private insurance market and the pricing structures that sustain it.
The internal documents obtained by The Intercept named Medicare for All as the primary target. PAHCF’s own public statements made clear that it opposed the public option as well. The American Medical Association left the coalition in 2020 partly because PAHCF’s opposition had expanded beyond Medicare for All to include the public option — a position the AMA found difficult to defend publicly. The expansion of the coalition’s targets tracked the expansion of reform momentum, not any principled distinction between reform proposals.
What this means for understanding the coalition is that its target is not a specific bill. Its target is the structural reform of a system that currently generates substantial profits for its members. Any bill that meaningfully reforms that system is a target, regardless of its specific mechanism.
The Civic Side in Colorado and Connecticut
The public option campaigns in Colorado and Connecticut had genuine civic support. Advocacy organizations, patient groups, labor unions, and consumer organizations worked to advance the legislation. They ran their own campaigns, mobilized their own constituencies, and engaged their own lobbyists.
They lost — or more precisely, they won weakened versions of what they sought, after the industry had successfully stripped the most structurally significant elements from the legislation.
The asymmetry was not primarily financial, though PAHCF’s spending dwarfed what advocacy organizations could deploy. The deeper asymmetry was structural. The advocacy organizations that supported the Colorado public option built campaigns around that specific legislation in that specific session. When the session ended and the weakened bill passed, those campaigns concluded. The institutional knowledge they had developed about the Colorado legislative process, the specific pressure points in the state hospital industry’s lobbying operation, the arguments that had moved and failed to move specific legislators — that knowledge did not accumulate in a shared repository available to the next reform effort. It dissipated with the campaigns that had generated it.
PAHCF’s Colorado operation did not dissipate. The relationships its lobbyists built with Colorado legislators in 2021 remained. The institutional knowledge of Colorado’s regulatory environment remained. The financial infrastructure remained available for deployment if reform surfaced again. The continuous operations model compounds. The campaign model resets.
How America’s Plan Addresses This
The state battlefield documented in this article is the civic infrastructure problem made concrete and geographic. The same structural failure that allows episodic civic campaigns to be defeated by continuous institutional operations at the federal level operates identically at the state level — with the additional disadvantage that the civic side’s resources are typically thinner at the state level and the organized interests side’s relationships with state legislators are often more direct and established.
America’s Plan’s Commons is designed to address the specific failure the Colorado and Connecticut campaigns illustrate: the loss of accumulated knowledge when campaigns end. The analytical record of how PAHCF’s state operation worked in Colorado — the specific spending, the specific legislative pressure points, the specific concessions that were extracted — belongs in a shared repository that reform advocates in other states can access before their own campaigns begin, not after they have lost the same fights Colorado lost.
The connective layer the platform is designed to build — linking organizations working on related problems across organizational boundaries — addresses the fragmentation that the state-level campaigns illustrate. Patient advocacy organizations in Colorado, consumer groups in Connecticut, and labor unions in Nevada were working on the same structural problem against the same coalition with no mechanism for sharing what they had learned. The organized interests side shared its infrastructure across all three states. The civic side rebuilt from scratch in each one.
The platform cannot create resources the civic side does not have. It can prevent the resources that exist from being lost between campaigns — and it can connect the organizations doing parallel work so the knowledge they generate compounds rather than dissipates. That is a structural response to a structural problem. It is not a guarantee of outcomes. It is the difference between building and starting over.
Sources: Jacobin — Health Care Lobbyists Are Trying to Block the Public Option at the State Level (May 2021); Newsweek — After Joe Biden Broke His Health Care Pledge, Emboldened Lobbyists Are Targeting the States (May 2021); Connecticut Citizen Action Group — Insurance Industry Spent More Than $1.3M to Kill Public Option Legislation (2021); The Intercept — PAHCF Lobbied Against Affordable Health Care as Coronavirus Crisis Grew (April 2020); The Lever — Where Did the Public Option Go? (August 2022); OpenSecrets — Layers of Lobbying: An Examination of 2021 State and Federal Lobbying (June 2022); The Intercept — Lobbyist Documents Reveal Health Care Industry Battle Plan Against Medicare for All (November 2018); PNHP — AMA Drops Out of Group Opposing Medicare for All (2020).
The complete PAHCF Series
01 — What It Is and Why It Exists
02 — Who Funds It and What the Money Buys
03 — The Federal Strategy
06 — The Tobacco Playbook
The Organized Interests Playbook: A Structural Analysis of PAHCF
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