Wary of the political risks and practical difficulties of Medicare-for-all proposals that would move every American into a government health plan, Democrats increasingly are embracing more modest plans to use Medicare to expand insurance coverage.
This strategy — backed by former Vice President Joe Biden as well as other Democratic presidential hopefuls and leading members of Congress — would give Americans the option to sign up for Medicare, the half-century-old government plan currently reserved for the elderly and disabled.
But it would not mandate government coverage, effectively allowing Americans to retain their current commercial health plans.
Even this more incremental approach marks a significant leftward shift by Democrats: A decade ago, during the Obama administration, party lawmakers eschewed such an expansion when they passed the Affordable Care Act, often called Obamacare.
It stops well short, however, of the more expansive Medicare-for-all plan that Sen. Bernie Sanders (I-Vt.) has made a central plank of his 2020 presidential campaign.
The debate over how to expand health coverage has highlighted the most significant policy difference so far among the many people seeking the Democratic presidential nomination.
Although it’s too soon to know how the issue will be resolved, expanding Medicare choice seems to be emerging as the preferred strategy — supplanting Medicare for all, which just months ago looked to be a litmus test for Democratic candidates.
Sanders remains committed to Medicare for all, and he and his allies on the left wing of the Democratic Party dismiss more limited proposals as inadequate to address the healthcare affordability crisis faced by tens of millions of Americans.
“We need a president who will not back down until every American is guaranteed healthcare as a human right, period,” said Josh Orton, a senior advisor on the Sanders campaign.
Many on the left warn that compromising on Medicare for all would repeat what they see as the mistake Democrats made in 2010, when they settled on a centrist solution for expanding coverage in hopes of winning support from Republicans and centrist Democrats. The GOP instead spent the last decade trying to overturn Obamacare.
Four of the Democratic senators seeking the presidential nomination have endorsed Sanders’ bill proposing Medicare for all: Cory Booker of New Jersey, Kamala Harris of California, Kirsten Gillibrand of New York and Elizabeth Warren of Massachusetts.
Booker and Harris, however, appear to have backed away from the plan in recent months, saying that although they support Medicare for all, they do not want to eliminate private insurance.
And Warren, despite her embrace of many liberal positions, has assiduously avoided being tied too closely to Medicare for all, saying at a CNN town hall in March that she’s open to “different pathways” to achieve universal coverage.
When he kicked off his campaign two weeks ago, Biden told a crowd in Pittsburgh, Pa., that he believed Medicare should be a “choice” for people unhappy with their current coverage.
That approach reflects the political and logistical challenges of moving to a so-called single-payer system.
“ ‘Medicare for all’ sounds like something that would be very popular,” said former California Rep. Henry Waxman, a liberal Democrat who over four decades in Congress championed multiple expansions in coverage, including the 2010 healthcare law.
“The problem is that many don’t realize the flaws of making Medicare the only choice.”
The growing recognition of the difficulties has been underscored by polls showing that, although Medicare for all remains popular in the abstract, many Americans are leery of the potential trade-offs.
A survey earlier this year by the nonprofit Kaiser Family Foundation, for example, found that support for a single government plan fell from 56% to 37% when respondents were told that such a plan might involve eliminating private insurance companies or requiring more taxes. The foundation has no affiliation with the Kaiser Permanente health plan.
Making Medicare an option out-polled Medicare for all 74% to 56% in the Kaiser poll.
Another national poll, by Morning Consult, found supporters of Medicare for all were as likely to put a top priority on having Congress create an optional government plan for Americans as they were to say Medicare for all should be the top priority.
These results are not surprising, said Celinda Lake, a longtime Democratic pollster. “Medicare for all has transitioned from a goal to an actual policy,” she said. “The conversation has become more real.”
In addition to worrying voters who have employer-based coverage, the push for Medicare for all has also concerned elderly Americans, many of whom see it as potentially threatening to their own Medicare coverage.
The Trump administration and its congressional allies have tried to capitalize on those fears in recent months, working to undercut the political advantage that Democrats have enjoyed on healthcare since Republicans undertook their unpopular effort to repeal the Affordable Care Act.
Senate Majority Leader Mitch McConnell of Kentucky routinely refers to Sanders’ plan as Medicare for none, and President Trump has made repeated efforts to use the Medicare-for-all initiative and other Democratic policy ideas to tag the party as socialists.
Although Biden, the early front-runner, and other Democratic presidential contenders have yet to detail their preferred alternatives to Sanders’ Medicare-for-all bill, one possible blueprint is contained in legislation sponsored by two liberal House Democrats that would expand Medicare eligibility while preserving the current system of job-based coverage that most working Americans rely on.
The Medicare for America bill — co-authored by Reps. Rosa DeLauro (D-Conn.) and Jan Schakowsky (D-Ill.), in concert with the Center for American Progress — contains ambitious provisions to fold Medicaid and other government programs into Medicare. It has 16 co-sponsors, including Rep. Ro Khanna (D-Fremont), a top advisor to the Sanders campaign. Khanna signed onto the bill last week. Former Rep. Beto O’Rourke also backs their proposal.
Schakowsky, who also backs Medicare for all as a goal, stressed that the two approaches were not incompatible.
“Medicare for America is still a bold plan. It just may not be as threatening,” she said. “And we would get to test out a lot of things that could be applicable if we go to Medicare for all.”
More immediately, House Speaker Nancy Pelosi (D-San Francisco) is urging Democrats to focus on strengthening the current healthcare law, a move that is broadly popular and has spurred Republicans to remain on the defense politically.
House Democrats this week plan to advance a series of bills to reverse the Trump administration’s efforts to undermine the 2010 law.