"Medicare for all" has become a litmus test for 2020 Democrats, but the party is struggling to balance the grassroots enthusiasm for the cause with the political challenges of making it a reality.
Kamala Harris was the latest candidate to come under fire from the left, right and center. In a widely watched CNN town hall, the California senator embraced Medicare for all and said she was ready to see the private health insurance industry killed off. But she and her staff later offered a more nuanced story: Harris also backs many incremental, go-slow plans that aren’t as radical and add up to something more like “Medicare for more” or a strengthened version of Obamacare.
Harris’ struggle shows just how hard it is for Democrats to sell a more ambitious universal health care vision demanded by the activist left of the party while trying to appeal to the broader general election audience that shies away from Medicare for all proposals that abolish private health care coverage — all while remaining vulnerable to attack by the GOP and much of the health care industry as “socialized medicine.” Key health industries are already linking arms to lobby against a “government-takeover.”
Like many of her fellow 2020 hopefuls, Harris is appealing to both Democratic camps, co-sponsoring both full Medicare for all and variations of Medicare for more, including bills that would create an optional Medicare buy-in nationwide, establish a public option on Obamacare’s exchanges, allow states to open Medicaid to all residents and shore up the existing framework of the Affordable Care Act, which has been undercut in several ways by the Trump administration.
It’s a strategy shared by Sens. Cory Booker (D-N.J.) Kirsten Gillibrand (D-N.Y.), Elizabeth Warren (D-Mass.) and Jeff Merkley (D-Ore.), who have all signed on to health care expansion bills. Even Sen. Bernie Sanders (I-Vt), whose 2016 campaign pushed Medicare for all from the fringes to the Democratic mainstream, has endorsed models that would expand public insurance and strengthen Obamacare while keeping the private insurance market in place.
But it’s easy to be nuanced and back several policy approaches as a senator; it’s a lot tougher for someone seeking to define herself as a potential Democratic presidential nominee, particularly in an crowded field. Harris’ presidential campaign launch and the ensuing burst of support has come with heightened scrutiny from the right and the left.
Responding to charges her support for more gradual health reforms showed she is wavering or reneging on Medicare for all, Harris’ communications director Chris Harris tweeted this analogy: "I want a burrito. I’d accept tacos in the meantime, but I want a burrito." In other words, she wants Medicare for all, but recognizes that there are other steps that can be taken to cover more people in the interim.
“She has co-sponsored other pieces of legislation that she sees as a path to getting us [to Medicare for all], but this is the plan she is running on,” campaign spokesperson Ian Sams told POLITICO.
Recent polling has shown both high overall support for Medicare for all and the challenges Democrats face in educating the public on the potential costs and benefits of each particular plan. A University of Chicago survey this month found that a majority of people believe, incorrectly, that public insurance would be optional under Medicare for all and that they would be able to keep their private health coverage. Many people surveyed were similarly ill-informed on who would be eligible under a single-payer model, what benefits would be covered and how much it would cost.
Another poll by the Kaiser Family Foundation found that support for Medicare for all swings depending on how it’s presented — which is a problem for Democrats since they don’t all have the same definitions. Nearly 70 percent support the idea after hearing that it would eliminate health insurance premiums and reduce out-of-pocket costs. But approval plummets to below 40 percent when people are told they might have to pay more in taxes and that private health insurance would be eliminated.
In this information void, Harris and other prospective candidates are scrambling to define the parameters of the Medicare for all debate and thread the needle between lofty goals and pragmatic concerns.
"It’s an important rallying cry and I say amen to that. But it’s important to lay out a route about how we get to that vision," said Merkley, who is both a co-sponsor of Sanders’ Medicare for all plan and the author of a bill to create a Medicare buy-in for individuals and employers. "Instead of telling everyone that they have to choose Medicare, it’s a huge stride in the direction of a simple, seamless system of access to health care."
Sen. Brian Schatz (D-Hawaii), whose Medicaid buy-in plan Harris has also endorsed, said the party’s top concern should be "how to cover the most people the most quickly."
Sen. Sherrod Brown (D-Ohio), one of the few Democrats exploring a bid for president who has not endorsed Sanders’ bill, has said he prefers to start with a buy-in plan for people 55 and older — a model much likelier to appeal to Republicans, independents and moderate Democrats. He has also proposed a Medicare buy-in just for police and firefighters who retire early.
"I see this as good policy advancing toward universal coverage," Brown said. "It’s easy to say Medicare for all and make a good speech but see no action, and I want to see action. I’m not going to judge other bills, but these are good policies that will expand health care to a lot more people who are deserving."
Polling shows that these incremental public plans are much more popular across the political spectrum than Medicare for all, with more than 75 percent of the public in favor.
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Karen Pollitz, a senior fellow at the Kaiser Family Foundation, said such a model would allow Democrats to sidestep some major risks.
"Our public opinion polling shows that most people like Medicare for all and universal coverage. But when told they would have to give up the health plan they have now, that support goes way down," she said. "It reflects a fundamental nervousness people have about having their coverage taken away even if you promise them something better."
Fear of losing a familiar health plan helped kill President Bill Clinton’s health care initiative in the 1990s and fueled an enormous backlash after President Barack Obama promised during the passage of the Affordable Care Act that people could "keep what they have" only to see many people lose skimpier but cheaper health plans that didn’t meet ACA benefit standards.
But some lawmakers and outside progressive groups say now is not the time to settle for less.
Bonnie Castillo, the executive director of National Nurses United, a union that has mobilized its 150,000 members to push or Medicare for all, told POLITICO that calling for anything less than full single-payer health care shows a weak hand.
"Don’t start bargaining with yourself and undermine yourself," she said. "The opposition, the insurance companies and pharma, they will come out against anything, whether it’s a half-measure or even a one-quarter measure. That’s why we have to aim high."
The 2020 primary could see Democrats forced to unite around a single health care plan, and single-payer advocates in Congress couldn’t be happier with Harris using her platform to stump for the issue.
"Kamala Harris doubling down on Medicare for all, both in her speech and in her town hall — that’s enormous momentum for us," Rep. Pramila Jayapal (D-Wash.), the lead author of the House’s plan, told reporters Tuesday.
The Democratic nominee, lawmakers stressed, will indicate the health care path voters want the party to take.
"Presidential candidates and campaigns have big bully pulpits," Merkley said. "And a way for people to express support for a vision is to choose a candidate."