House Majority Whip James E. Clyburn cut short an appearance Friday with liberal activists, having been summoned to a Democratic leadership meeting where one of the topics was the very issue he had been discussing, which is expanding health care access for the working poor.

“Please, go to your meeting, Mr. Clyburn,” Patrick Gaspard, the former ambassador to South Africa, told the South Carolina Democrat.

Clyburn dropped down one floor to the offices of House Speaker Nancy Pelosi (D-Calif.), where she had gathered key committee leaders to discuss the elements of President Biden’s proposed multitrillion-dollar domestic policy bill. One of the centerpieces of the legislation would expand health care coverage in three different areas, each with a powerful patron who represents a critical portion of the Democratic coalition.

Clyburn, the highest-ranking Black member of Congress, is focused on expanding Medicaid in states that have declined to accept an infusion of federal money that was made available by the 2010 Affordable Care Act (ACA), leaving an estimated 2.2 million without insurance, primarily people of color since eight of those 12 states are in the South.

But Sen. Bernie Sanders (I-Vt.), runner-up for the Democratic nomination to Biden and chairman of the Senate Budget Committee, is focused on expanding Medicare’s options for the elderly to include services such as dental, vision and hearing. While it is not as ambitious as his universal health plan, supporters of Sanders view it as a down payment on his Medicare-for-all plan, which has deep support among young liberals.

And Pelosi has long made clear that her imperative is to shore up the ACA, her biggest achievement in her first turn as speaker, and the plans would reinforce subsidy programs that prevent premiums from soaring.

This law, while initially unpopular, proved to be well-liked by voters once it took effect the middle of last decade. When then-President Donald Trump and Republicans tried to repeal the health law, Pelosi helped stoke a revolt across the suburbs, particularly among women, that prompted the 2018 Democratic landslide that allowed her to reclaim the speaker’s gavel.

If Democrats can forge near-perfect unity, then they will be able to pass a historically ambitious bill that will include all three of these benefits. But in recent weeks, centrists in the House and Senate have opposed the massive price tag — $3.5 trillion in proposed new spending over 10 years — forcing Democrats to ponder what proposals need to be trimmed.

Officially, Democrats remain solidly behind all three health proposals, as well as a fourth plan, reducing the cost of prescription drugs, a policy goal they have chased for more than two decades on Capitol Hill.

“I think they’re all important. I mean, how do we not do them? They’re an important part of Biden’s agenda. They’re important in terms of providing people health insurance. I still think that we can do all of them,” said Rep. Frank Pallone Jr. (D-N.J.), chairman of the House Energy and Commerce Committee, which has drafted much of the health policy in the plan.

Clyburn was probably embellishing the urgency of his attendance at the Pelosi meeting, to please the crowd watching the Center for American Progress webcast, given that these huddles are now taking place on a daily basis. But he wanted to send a message to those activists that he considers expanding Medicaid coverage as part of the arc of the civil rights march that he first joined over 60 years ago. Left unspoken — but well understood by everyone in Congress and the White House — is his clout.

In February 2020, as Biden’s presidential bid floundered in early primary states, Clyburn endorsed him just ahead of the South Carolina primary, and Black voters there rallied around the former vice president to deliver him a decisive win. A few days later, Black voters in other Southern states delivered a similar showing for Biden in the Super Tuesday states, putting him well on his way to locking up the Democratic nomination.

Last fall, Black voters in Georgia turned out in historic numbers to flip the state to the Democratic column the first time this century and, in January, they turned out in significant numbers again to deliver two runoff elections for Democrats to secure the Senate majority on Capitol Hill.

Now Clyburn wants to deliver for the roughly 2.2 million people who sit below the federal poverty line but have no health insurance because their governors would not accept the ACA’s Medicaid expansion. Given the rightward tilt in states like Alabama, Mississippi and South Carolina, this might be his best chance to deliver. “These states are not going to expand Medicaid, at least not in my lifetime,” Clyburn, 81, said Friday.

Sanders retains a devoted following of millions, largely younger voters, who consider themselves progressives first rather than party-line Democrats. After finishing behind Biden, Sanders played a unifying role by pitching for him in the general election, much more so than four years earlier when tensions remained palpable after he finished behind Hillary Clinton.

Sanders, 80, is also pushing a benefit to a bloc of voters — the elderly — who are the most reliable to cast ballots in midterms, so his Medicare push could offer a double political bounce. Moreover, Sanders has so far had the ear of Senate Majority Leader Charles E. Schumer (D-N.Y.), who has embraced the Medicare proposal as a top priority. It’s an open secret that Schumer is looking ahead to next year’s primary in New York with a possible primary challenge from his left, and a strong endorsement from Sanders would make the already strong Schumer almost unbeatable.

Yet Pelosi, 81, has been the most powerful Democratic figure on Capitol Hill for at least 15 years, with more than her fair share of policy victories. When liberals pushed for Medicare-for-all in early 2019, Pelosi politely dismissed it and urged Democrats to focus on ACA’s generous subsidy system. “We all share the value of health care for all Americans — quality, affordable health care for all Americans,” Pelosi said in a 2019 interview. “What is the path to that? I think it’s the Affordable Care Act.”

Swing-district Democrats favor the ACA proposal because it would fortify a health subsidy system already in place, delivering instant benefits to voters ahead of next year’s midterm elections. The Medicare proposal is more complicated because it would take several years for federal regulators to implement a payment system for dentists and other doctors.

But if that proposal is only in practice for a few years over the next decade, its price tag might be more affordable than the other two major health proposals. The period used by Congress to assess the cost of legislation is 10 years. During the Medicaid discussion, Clyburn acknowledged that ambition had to be scaled back, comparing this drive to how civil rights activists won new laws on voting and labor over many years.

Clyburn is willing to get a few years of Medicaid expanded for more health coverage, which he believes will be harder to strip away once implemented. “You don’t get the whole loaf,” he said, “every time you start out.”