Since 2009, Big Pharma has given a decent amount of money each year to the Third Way Foundation, the parent of the Progressive Policy Institute, a center-left think tank with ties to Democratic Party leadership. The giving wasn’t astronomical, ranging between $25,000 and $75,000, but in 2016, the health care debate in the Democratic Party got real, and the contributions swelled, as Sen. Bernie Sanders gave Democratic frontrunner Hillary Clinton a scare, running on Medicare for All as a signature issue.

According to tax records, PhRMA, or the Pharmaceutical Research and Manufacturers of America, upped its gift that year to $265,000. With Donald Trump in the White House, PPI’s haul in 2017 from the drugmakers was back to normal, at $50,000, bringing the total since Barack Obama was inaugurated to $615,000. Figures for 2018 aren’t yet available yet, but PhRMA has been getting its money’s worth from PPI, as the group plays a leading role in opposing the Democratic Party’s move toward single payer.

Three years after Sanders’s first run, public opinion has shifted overwhelmingly in support of Medicare for All. Yet in its latest report “A Radically Pragmatic Vision for Universal Health Care,” PPI has worked to cast a majoritarian position as the handiwork of some fringe leftists.

PhRMA, which depends heavily on government patents and money for research and development, has teamed up with other health care interest groups to try to crush the movement for a single-payer system, and spent $28 million on lobbying last year — but that’s only what it had to report. Gifts to groups like PPI don’t legally count as lobbying.

PhRMA is part of a coalition of insurance providers, pharmaceutical companies, and investor-owned hospitals in the Partnership for America’s Health Care Future strategizing to defeat Medicare for All. The Intercept reported in November that PAHCF pushed Democratic candidates to run on saving the Affordable Care Act rather than supporting Medicare for All. And Democratic leadership won’t get behind single payer, with House Speaker Nancy Pelosi advocating instead to fix the ACA and arguing that we just can’t pay for a nationalized health care system.

On Tuesday, the House will hold its first hearing ever on Medicare for All.

The financial ties between health care industry interest groups and the Democratic establishment are well documented. Sludge and MapLight reported this week that employees and political action committees for PAHCF members have given at least $1.3 million in direct contributions to the Democratic Congressional Campaign Committee since 2009. Some of the lobbyists and firms that have helped the DCCC raise almost $1 million of its $32 million haul in the first quarter of 2019 have represented at least 12 members of the coalition, including PhRMA and the Federation of American Hospitals, Andrew Perez and Alex Kotch reported.

PPI, in its rhetoric, focuses on fixing the ACA and lowering drug prices and says that its findings are independent of any fundraising. “First, the Pharma support has nothing to do with any position we take on policy issues,” PPI Executive Director Lindsay Lewis told The Intercept in an email. “We don’t do paid for work or paid for outcomes and our researchers do not know our donors on purpose so they can remain independent,” he said. “Second, on the issue of medicare for all, we have had the same policy thoughts for 25 years and have not changed. We believe strongly that we need to improve on the ACA and we want to find a way for universal coverage but single payer is not the right way to achieve that goal. Although I can guess that Pharma is opposed to medicare for all I have never had that conversation with them.”

PPI is the think tank wing of the now-defunct Democratic Leadership Council, a faction of the party that organized in 1985 with the aim of curbing the party’s tilt further left in response to Ronald Reagan’s presidency. The DLC, previously chaired by Bill Clinton, was known for embracing free market, corporate-friendly policies to woo big donors. PPI argues that the most viable solution to close massive gaps in health care coverage and bring down unreasonable prices is to fix the ACA and preserve both private and public options. They warn that an agenda that is too progressive will scare away swing voters, and see the battle for the Democratic Party as a test of who can win back people who flipped from Obama to Trump, rather than a challenge of turning out new or disenchanted voters.

PPI earlier this month held a forum in Iowa on “Progressive Alternatives to Nationalized Health Care” with former Colorado Gov. John Hickenlooper, a Democratic presidential candidate. The group’s president and founder Will Marshall argued that while Americans may like the idea of nationalized healthcare on paper, once the details are spelled out, “some of that support melts away,” he told the Des Moines Register. Recent polling from the Kaiser Family Foundation shows that while enthusiasm for Medicare for All has increased over time, and that the majority of Americans currently support it, that support falls off when respondents are told that the plan would delay treatment time, increase taxes, and eliminate private health insurance companies.

The group released a report shortly after the Iowa event in which it argued that “activists are trying to force Democrats to embrace ‘Medicare-for-all’ as a magic pill for all that ails our health care system. PPI urges progressives to push instead for less disruptive and costly ways to align incentives to spur innovation and improve health care delivery in both the private and public sectors.”

It’s not unusual for PhRMA to give to nonprofits, health groups, political think tanks, and other Hill groups. It does so frequently to places like the American Enterprise Institute, the Congressional Black Caucus Foundation, the Heritage Foundation, and others, alongside the Third Way Foundation.

PPI is adamant that its corporate support has no influence over its policy positions. In a response to a request for the group’s latest annual report, Lewis told The Intercept, “Our researchers do not know our list of donors nor what they give, we have no donor control or donor board, our writers are independent and free to come to any conclusions they have. If you are attempting to question the integrity of our writers and researchers I would think clear evidence would be needed (it doesn’t exist because its a false narrative).”

Third Way — which is not related to the Third Way Foundation, another center-left, corporate and GOP donor-funded nonprofit pushing neoliberal economics and a focus on opportunity over inequality — has also been vocal in pushing against Medicare for All. Third Way has attacked the popular program as “risky.” Co-founder and senior vice president of public affairs Matt Bennett told USA Today that the proposal is “irrelevant at best and at worst a serious distraction” from trying to save the ACA. Third Way argues that even Democratic primary voters don’t want to go too far left, pointing to 32 candidates endorsed by the New Democrats who won primaries out of the 37 that the New Dem caucus endorsed in 2018. But eight of those candidates were uncontested, 17 were virtually uncontested due to extreme fundraising disparities, and three were actually progressives in the mix — two of whom supported Medicare for All. Out of the eight remaining races in which candidates actually opposed each other ideologically, New Dems only won three.

At least 48 incoming members of Congress ran on universal health care, and Democrats seeking the White House in 2020 are coalescing around the idea. Sanders introduced a Medicare for All bill in the Senate earlier this month, with fellow presidential hopefuls Sens. Cory Booker, Kamala Harris, Kirsten Gillibrand, and Elizabeth Warren co-sponsoring it. Congressional Progressive Caucus Co-Chair Pramila Jayapal introduced the House companion bill last month. It has 108 co-sponsors.

Despite all that momentum, Democratic leadership still won’t budge. A top health policy aide to Pelosi told insurance executives in December that they could count on Democrats to help fight against single-payer health care. Wendell Primus urged insurers to join Democrats in focusing instead on lowering prescription drug prices. Pelosi herself has demurred on the issue, saying in the past that she generally supports the idea of universal health care, but arguing more recently that Medicare for All isn’t as good as the Affordable Care Act. In a February interview with Rolling Stone, Pelosi returned to a favorite, if not lazy, critique reserved for progressive ideas that the party can’t quite wrap its head around: “How do you pay for that?”

Congress authorizes spending every year for programs like Medicare, Medicaid, and the Children’s Health Insurance Program. The U.S. already spends $1.1 trillion every year on health care. Included in those annual authorizations are hundreds of billions of dollars in defense spending, and billions for Trump’s border wall. Most opposition to the idea of single-payer health care comes back to the deficit. But that wasn’t a concern when Trump green-lit a $100 billion increase in defense spending last year.

The government can authorize spending on whatever it wants. The U.S. hasn’t been tied to the gold standard for almost 50 years, but policymakers still behave as if they can run out of dollars. The issue isn’t that a national health care system couldn’t be financed — it’s about appeasing a set of interlocking industries that depend on the status quo prevailing.

“Medicare For All would save individual families thousands of dollars a year and save the American health care system trillions by eliminating duplicative costs across insurance companies, zero’ing out billions in advertising costs, and ending excessive CEO pay,” Adam Green, co-founder of the Progressive Change Campaign Committee, told The Intercept in an email.

“Medicare For All would also ensure families can use whatever doctor they like, even if they switch jobs or lose their jobs — and people would be happier as dental, vision, and home long-term care are covered and co-pays and deductibles are eliminated,” Green said. “The only ones who understand Medicare For All and oppose it are the Big Insurance and Pharmaceutical companies who will finally have their power challenged — and the corporate-funded think tanks who are paid to give Democrats losing political advice.”