BURLINGTON, Vt. — In July 1987, Bernie Sanders, then the mayor of Burlington, Vt., arrived in Ottawa convinced he was about to see the future of health care.
Years earlier, as his mother’s health declined and his family struggled to pay for medical treatment, he was spending more time attending to her than in classes at Brooklyn College, suffering through what his brother called “a wrecked year’’ leading to her death. Over time, he had come to believe that the American health care system was flawed and inherently unfair. In Canada, he wanted to observe firsthand the government-backed, universal model that he strongly suspected was better.
Amid tours of community centers and meetings with health care providers, Mr. Sanders more than liked what he saw.
“He was thrilled,” recalled Beth Mintz, a professor of sociology at the University of Vermont and a member of a task force that accompanied Mr. Sanders. “It gave him much more confidence in the possibility of the single-payer system as a solution.”
Decades before “Medicare for all” would propel his presidential campaigns, Mr. Sanders’s expedition to Ottawa helped forge his determination to transform the American health care system. His views burst onto the national political scene during his 2016 presidential run, when he championed a single-payer program alongside many other liberal policy ideas. Now, as he seeks the Democratic presidential nomination for a second time, he has made “Medicare for all” the most important issue of his campaign and set the agenda for the ideological discussion in the primary.
Health care dominated the first two Democratic debates this summer and will most likely be prominent again during the third debate on Thursday in Houston. Other candidates support “Medicare for all,” but it is Mr. Sanders who has become singularly identified with it — “I wrote the damn bill!’’ he proclaimed in July’s debate.
A review of hundreds of pages of documents from the first chapters of his political career — including speeches, correspondences and newspaper clippings — as well as interviews with those who have known him throughout his life, show that while his democratic socialist worldview underpins his “Medicare for all” pitch, he was also guided by other factors. Chief among them were his mother’s illness and death, which instilled in him the desire to ensure everyone had access to medical care, and the adjacency of Vermont to Canada, which afforded him a blueprint for universal health care.
Together, they help explain why he has staked not only his campaign, but also much of his political legacy, on promoting “Medicare for all.’’
“You can’t overstate the impact that Vermont’s proximity to Canada had on Bernie’s thinking about how to approach reforming the American health care system,” said Jeff Weaver, who has worked with Mr. Sanders since the 1980s and remains one of his closest advisers. The pull of Canada remains strong: In July, Mr. Sanders took a bus trip from Detroit to Windsor, Ontario, with diabetes patients to highlight lower drug prices in Canada.
In an interview on Sunday, Mr. Sanders described how seeing the Canadian system up close significantly shaped his own views on health care.
“It was kind of mind blowing to realize that the country 50 miles away from where I live — that people could go to the doctor whenever they wanted and not have to take out their wallet,” he said.
“That was just a profound lesson that I learned,” he said.
He also criticized the American system as “barbaric.” And he vowed — as he often does in his stump speeches — “to take on the greed and the corruption of the health care industry.”
Mr. Sanders’s health care proposal has attracted legions of supporters fed up with the rising costs of the current system, and it sets him apart from more centrist candidates like Joseph R. Biden Jr. But his uncompromising position also threatens to alienate voters who are pleased with the Affordable Care Act, or who do not want to give up their private insurance. His own state of Vermont so far does not have a single-payer program.
Despite skepticism about his views, however, Mr. Sanders has consistently resolved to reform the health care system, even before being elected to public office. In 1972, when he was running for Senate as a candidate from Vermont’s left-wing Liberty Union Party, The Bennington Banner, a local newspaper, reported him taking an uncompromising stance: “There is absolutely no rational reason, in the United States of America today, we could not have full and total free medical care for all.”
The challenge of paying medical bills
The first seeds of Mr. Sanders’s concern were sown in Brooklyn.
A high-school track and cross country star with an emerging political streak, Mr. Sanders had wanted to go to Harvard, friends said. But by his senior year, his mother, Dorothy Sanders, had become sick, her heart damaged from having rheumatic fever as a child.
As her health declined, her illness consumed him. He stopped going to track practice. To be closer to her, he began his freshman year at Brooklyn College.
Mr. Sanders describes his family as lower middle class. His father, an immigrant from Poland, was a paint salesman. He has said his parents frequently argued about money.
When his mother fell ill, his family moved her into a charity hospital in New Jersey. After a failed heart surgery, she died in March 1960, when she was in her mid-40s. “Bernard actually spent much more time with her than he did in class,’’ his brother, Larry, recalled in an interview in February. “It was really a kind of wrecked year and a very unhappy year.”
Then, as now, Mr. Sanders avoided speaking of his mother’s death. On Sunday, he declined to discuss his personal life, but said that his family had “struggled economically, and that’s it.”
In a 2006 interview with Vermont PBS, he offered a glimpse into how her illness shaped his thinking.
“When you talk about money and family, how do you get the money for the medical treatment that my mother needed?” he said. “I won’t go into the whole long song and dance of it. But trust me, it was something that I also have not forgotten about — the right of people to have health care, which was a little bit difficult in our family situation.”
It would still be some years, though, before health care became his political hallmark.
Mr. Sanders transferred to the University of Chicago, where he spent hours in the library reading progressive publications that would influence his political views. There, he turned his energy toward civil rights.
“We didn’t talk about health care,” said one of his roommates, Ivan Light. “It was not on the political agenda at that time. Civil rights was on the agenda.”
After moving to Vermont, he became active in politics. A perennial candidate with the Liberty Union Party in the 1970s, he focused on issues like the tax structure.
But he also began to study health care seriously. Included in a collection of papers from those days are pamphlets, articles and other material related to medical care. One publication he saved from March 1972 was titled, “Health Rights News;” its slogan was “Health care is a human right.”
That research soon began to take hold: In October 1976, when he was the Liberty Union candidate for governor, he told The Burlington Free Press that the delivery of medical care was “basically a national problem” and that he supported “public ownership of the drug companies and placing doctors on salaries.”
“I believe in socialized medicine,” he said.
John Bloch, who has known Mr. Sanders since the 1970s when they were active in Vermont politics, said he thought Mr. Sanders’s views were influenced in part by the people he lived near in the rural town of Stannard, Vt., many of whom were in desperate need of health care.
“He didn’t just come to this as Johnny-come-lately,” Mr. Bloch said.
In the interview Sunday, Mr. Sanders said he was particularly affected at the time by a young boy who lived across the road whose teeth, he said, were rotting in his mouth.
Deb Richter, a Vermont physician and longtime advocate for single-payer health care, who has worked with Mr. Sanders on the issue for 20 years, said he had always felt that health care was a human right.
“You ask Vermonters, ‘How long has Bernie been talking about single-payer health care for all?’ and nobody can remember a time he wasn’t talking about it,’’ she said.
Turning his sights toward Canada
After Mr. Sanders was elected mayor of Burlington in 1981, he largely emphasized local issues, like property taxes and affordable housing. “I was the mayor of a city of 40,000 people,” Mr. Sanders said in the interview. “Talking about national health care is not exactly what you talk to the board of aldermen about.”
By then, he had also become somewhat fixated on Canada. In September 1981, he invited the director of the Quebec Insurance Board to speak about the province’s health insurance plan. Later, he demanded more accountability from the state’s health insurance company and encouraged a review of hospital budgets.
As he pondered higher office, his focus on health care intensified. Even before he announced his 1986 campaign for governor, he said he planned to run in part on controlling medical costs, according to an article in the Vermont newspaper The Times Argus.
He lost that race but gathered valuable information in the process: During his campaign, his team had polled Vermont residents on issues. “To my surprise,” Mr. Sanders said in 1987, “the issue that Vermonters felt most strongly about was the rapidly rising costs of health care.”
That finding served to galvanize his actions on health care. He quickly set up a task force and charged it with studying how to make the system more affordable.
Soon Mr. Sanders and the task force — which included an expert on the Cuban health care system, professors and a minister — were traveling to Ottawa, which had implemented a government-supported, single-payer system.
Jed Lowy, who went on the trip, recalled touring a public hospital, visiting a neighborhood community health center and speaking with physicians.
“It was interesting to see another way that health care was provided,” Mr. Lowy said.
That trip, and a later one to Montreal, reinforced Mr. Sanders’s idea that Vermont’s northern neighbor had effectively put into practice the kind of accessible, affordable system he had long sought.
At a news conference after the Ottawa visit, the task force suggested Burlington could model its health care system after Canada’s. And in unequivocal tones, Mr. Sanders said it would be “absolutely negligent” not to examine at least some aspects of the Canadian model.
In March 1988, the task force released a report recommending the creation of a national health care system.
Mr. Sanders’s focus on health care policy met some resistance at home from city employees reluctant to give up benefits they had earned.
Mr. Sanders forcefully rebutted the criticism.
“You may regard this as ‘propaganda’,” he wrote tersely in response to a letter from an angry constituent in December 1982. “I expect that you may not have talked to citizens who are taking their food money to pay for medical care.”
By the time Mr. Sanders was mounting his 1988 congressional run, he was speaking about health care in the kind of dogmatic terms he uses today, and he was broadening his vision beyond Vermont. He praised the National League of Cities for adopting a resolution to establish a national health system.
Soon after formally announcing his congressional campaign, he set forth his premier agenda item, one that he had imagined since his mother’s death some three decades earlier.
“I want to make it emphatically clear,” he said in April 1988, “that I will make health care reform a top priority as a United States congressman from the state of Vermont.”
Alexander Burns contributed reporting. Kitty Bennett and Alain Delaquérière contributed research.
