'Medicare For All' Is Turning Into A 2020 Litmus Test For Democrats

The party's voters need to decide how much it really matters.

Sherrod Brown has been calling for universal health care since 1992. That's when he first ran for a U.S. House seat in Ohio, vowing to decline the federally subsidized insurance for members of Congress until his constituents could get similar coverage. He won that race and he kept that pledge, buying policies on his own until 2011, after the Affordable Care Act became law.

He was a senator by that point, and like every other Democrat in the chamber, he voted for President Barack Obama’s signature health care law. But before Brown did that, he promoted a series of proposals designed to make the program more generous and comprehensive. One of them was a last-minute amendment that would have replaced Obamacare’s intricate scheme for competing private insurers with a “Medicare for all program, under which everybody would enroll in a government-run insurance plan.

Nobody seriously thought Democrats were about to scrap legislation they had spent nearly a year writing. By supporting the amendment, Brown was mostly trying to demonstrate his commitment to improving the Affordable Care Act, if not before it became law, then afterward. It was a symbolic act, but a conspicuous one, with only one other senator co-sponsoring it.

The amendment’s author was Sen. Bernie Sanders (I-Vt.), the most visible champion of “Medicare for all.” In 2016 he made the idea a centerpiece of his presidential campaign, and a year later, he introduced a new version of “Medicare for all” legislation ― this time, with 16 co-sponsors, proving just how popular the idea had become in the interim.

Sen. Sherrod Brown (D-Ohio) on "Late Night With Seth Meyers" on Jan. 23. Brown, who previously supported “Medicare for all,” now says he wants to focus on narrower ideas, like opening up Medicare to near-retirees, because they are more politically realistic.
Sen. Sherrod Brown (D-Ohio) on "Late Night With Seth Meyers" on Jan. 23. Brown, who previously supported “Medicare for all,” now says he wants to focus on narrower ideas, like opening up Medicare to near-retirees, because they are more politically realistic.
NBC via Getty Images

But this time Brown declined to join them, explaining in a prepared statement that while he remained “supportive of ‘Medicare for all,’” he preferred to focus on more incremental, potentially bipartisan measures, like allowing people to buy into Medicare as early as their 50s.

Now Brown is thinking about a run for president himself. And like every other Democrat who has launched a 2020 campaign or is seriously contemplating one, he has been getting questions about whether he will endorse “Medicare for all.” His answer has been “no,” and he has become more explicit about why, saying he doesn’t think it’s realistic politically.

“It’s easy to say ‘Medicare for all’ and make a good speech but see no action,” Brown told Politico in late January, “I want to see action.” This weekend, he told voters at an Iowa forum that “If we can get Medicare to 50, if we can pass Medicare at 55 tomorrow, two things would happen. A whole lot of people’s lives would improve, and a whole lot of voters would think, ‘Oh, that works. The next step is to do more.’”

Brown’s posture has already provoked criticism from progressives. If he proceeds with a presidential campaign, he can expect a lot more of it ― as can any other Democratic candidates whose commitment to “Medicare for all” seems suspect.

Just ask Sen. Kamala Harris (D-Calif.), who is running for president. After reaffirming on CNN last week that she supports “Medicare for all,” aides made clear (as they did previously) that she remained open to incremental steps or alternative methods of achieving universal coverage. Social media erupted with accusations from activists that she was watering down her position. So far, the only person who seems immune is Sanders, who may join the 2020 race.

None of this should be surprising. Presidential campaigns are all about making distinctions among candidates, and there are real differences between somebody like Brown, who doesn’t want to push “Medicare for all” right now, and somebody like Sanders, who does. But the question for Democratic voters over the next year and a half, as they choose their 2020 presidential candidate, is exactly what those differences reveal and, ultimately, which ones matter.

The Debate Over ‘Medicare For All’ Is Real Now

One thing that shouldn’t be in doubt is that nearly all the major Democratic 2020 candidates believe in universal health care coverage, which has been a core party value since President Harry Truman tried to create a national health program in the late 1940s.

Truman had in mind a government-run system that would cover everybody. When his effort crumbled in the face of lobbying by the American Medical Association and other health care industry groups, Democrats began a decades-long effort to get to universal coverage by some other method ― whether it was providing government-run insurance to just part of the population, as Medicare does, or preserving a large role for private insurance, as the ACA does.

The tilt toward private insurance coincided with a time when the Democratic Party as a whole had a more conservative orientation and its policy advisers had more faith in private enterprise and the forces of competition. Now interest in government-run insurance appears to be surging, partly because so many people still face high medical bills even with the ACA in place and partly because managing Obamacare’s complex markets has proved difficult, with Republicans constantly trying to undermine them.

Sen. Kamala Harris (D-Calif.) has said she favors “Medicare for all.” But she has also said she's open to other forms of universal coverage and would support incremental reforms on the way to universal health care coverage.
Sen. Kamala Harris (D-Calif.) has said she favors “Medicare for all.” But she has also said she's open to other forms of universal coverage and would support incremental reforms on the way to universal health care coverage.
Bloomberg via Getty Images

The 2017 Sanders proposal, which has become the de facto standard for progressives, would address these problems by creating a government-run plan that automatically enrolls everybody, covers every medically necessary service and asks beneficiaries to pay nothing out of their pockets when they visit the doctor or get a lab test. With taxes likely replacing premiums (the Sanders bill doesn’t fully specify financing) and the government setting prices for every kind of medical supply and treatment, the goal would be to reduce overall health care spending and leave most individuals better off.

The Sanders proposal would more or less eliminate private insurance because it would prohibit employers and private carriers from providing duplicative coverage. Promoters of the idea call this a feature, not a bug, because most people hate dealing with insurance companies anyway. They note, also, that the universal coverage schemes of most countries dramatically minimize or eliminate the role of for-profit insurers.

Still, proponents of the Sanders bill frequently gloss over the variety of universal coverage schemes overseas ― and the ways in which those systems differ from what his version of “Medicare for all” would mean here. Wealthier Germans, for example, can opt out of the government system and enroll in private plans, which for-profit insurers sell. Most of the French buy supplemental policies to cover their out-of-pocket costs, which include extra fees that some doctors are allowed to charge.

More important, perhaps, the national health insurance systems of nearly all those countries date back to the middle of the 20th century, when policymakers looking to enact reforms didn’t have to deal with a private health care financing system as entrenched ― and as expensive ― as the what the U.S. has now.

Trying to pass the Sanders proposal today would mean picking a fight not just with insurers but also with doctors and hospitals, drug and device makers, all of which have been known to protest even relatively moderate threats to their incomes.

These industries would run ads hammering away at the proposed program’s political vulnerabilities, of which there are many. Surveys have shown consistently that most Americans with private insurance like it, despite the hassles, and that support for “Medicare for all” drops precipitously when respondents hear it would mean having to give up the plans they have.

‘Medicare For All’ Isn’t The Only Path To Universal Coverage

Public opinion isn’t always clear, let alone fixed, so it’s impossible now to know how a debate over “Medicare for all” will play out once both sides make their most compelling arguments. Survey questions referring to upsides of “Medicare for all” push approval higher, just as questions that talk about would-be downsides push it lower.

But it’s easy to see how a politician who believes in universal health care might look at those poll numbers ― and think about the long, frustrating history of comprehensive health care reform ― and opt for changes less sweeping than what Sanders has in mind.

One option would be a proposal to create a government program that was open to all while giving employers the option to maintain their benefits and giving employees the option of staying with those. Such a plan would be closer to “Medicare for anybody” than “Medicare for everybody,” which is what the Sanders plan envisions. Reps. Rosa DeLauro (D-Conn.) and Jan Schakowsky (D-Ill.) recently introduced such legislation, which mirrors a proposal that the liberal think tank Center for American Progress released last year.

More limited options include proposals for opening up one of the existing government health care programs, Medicare and Medicaid, to additional people ― to those who are 55 or older, are in markets without much insurer competition or can’t get insurance through employers. Democrats could make the ACA’s financial assistance more generous or push for stronger government control of prices, not just for prescription drugs but for the rest of the health care system as well.

Each of these plans would be subject to substantive and strategic questions, just as the Sanders proposal is. Would the narrower proposals do enough to reduce prices throughout the health care system, so that people who already have insurance would see clear benefits? Would they generate enough enthusiasm from the public to overcome the resistance that even small-bore health care initiatives inevitably raise? And even if only more limited initiatives can pass in the near future, why start compromising on ideas now?

But the answers are not crystal clear, which is why Democratic voters passionate about health care might also want to pay attention to other questions, like which candidates have promoted universal coverage most consistently or which ones are thinking about Senate filibusters and other institutional obstacles to reform. Policy commitments on health care are important, but other factors matter too.

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