Like passengers leaping for a departing train, leading Democrats are scrambling to support single-payer health insurance, a system that would represent a huge expansion of government control over healthcare and which the party's presidential nominee declared last year would "never, ever" come to pass.
Sen. Bernie Sanders (I-Vt.), whose support for universal coverage was central to his 2016 presidential campaign, on Wednesday unveiled the latest version of his plan to expand Medicare to cover all Americans.
After a parade of testimonials about the failures of the nation's existing healthcare system, Sanders cast his measure as a moral and economic issue.
"Today we begin the long and difficult struggle to end the international disgrace of the United States of America, our great nation, being the only major country on earth not to guarantee healthcare to all of our people," Sanders said.
In the days before Sanders' announcement, Democrats as ideologically diverse as liberal Sen. Kamala Harris of California and conservative Sen. Joe Manchin of West Virginia expressed support for his effort. Their statements reflect a significant shift within the Democratic party, driven by multiple developments: a belief that the window has closed on Republican efforts to repeal Obamacare; a surge in support for government-run insurance among younger, more activist Democrats; and looming 2018 and 2020 contests that demand clarity on what Democrats support — not just whom they oppose.
Most of the party's potential 2020 presidential candidates have now endorsed the single-payer idea, including Sanders, Harris, Sen. Cory Booker of New Jersey, Sen. Elizabeth Warren of Massachusetts, New York Sen. Kirsten Gillibrand and Minnesota Sen. Al Franken.
Competing Democratic healthcare plans are due out soon, including one that would allow Americans to buy coverage through Medicaid and another that would expand Medicare, efforts less disruptive than Sanders' proposal. But the authors of both have cast them as bridges to a time when a single government plan can gain a majority.
The shift toward single payer brings risk for Democrats. The party suffered huge losses after attempts to restructure the nation's insurance system during the Clinton and Obama administrations.
And although polls show rising support for a government-run insurance plan, much of that increase comes among Democrats and Democratic-leaning independents — meaning the party will be pushing an approach nearly as partisan as President Trump's recent efforts to repeal the current healthcare law. (The president's press secretary, Sarah Huckabee Sanders, said Wednesday that Trump considers the new plan "a horrible idea.")
Moreover, public opinion appears less than solid. A recent Kaiser Family Foundation poll found support gyrating wildly when criticisms of a Medicare-for-all plan — including increased taxes and more government control over healthcare — were raised.
"People don't like uncertainty," said Lynn Vavreck, a UCLA political scientist. "Even the promise of something good might not be seen as better than what you have."
Already, elements in both parties are on the attack.
In Iowa, Republicans are accusing Democratic candidates for governor of supporting Sanders, citing a $32-trillion estimate for the senator's 2016 campaign plan. In California, the fight has been between competing Democratic factions, leading to the threatened recall of the Democratic Assembly speaker after he set aside a single-payer bill pushed by a powerful nurses' union because, he said, its financing was insufficient.
At his announcement, Sanders glided over the tough topic of how to pay for his proposal, saying only that "the average American family" would be better off and increased taxes "will be more than offset" by the absence of insurance premiums.
The swift embrace of a single government-run insurance program belies the long slog that veterans of the capital's healthcare wars predict would be required to sell the plan not only to a skeptical public but to legislators on Capitol Hill. For now, with a Republican president and both houses of Congress held by the GOP, the finish line is a distant one under most any calculation.
"I hate to break it to anybody, but we are realistically not within four years of having a single-payer bill or a universal coverage bill passed," said Andy Slavitt, who oversaw Medicare, Medicaid and insurance markets during the Obama administration.
"I strongly advise that Democrats invest the time in listening … [to] how people think about the trade-offs and how they think about the options and what features they'd like," he said.
Backers of the plan dismiss any political motives. Harris said Wednesday that the measure "is a nonpartisan issue."
Despite admonitions from experts like Slavitt, support for a universal government program rapidly is becoming a litmus test for the party's national and state candidates.
"It's going to be hard to win a Democratic primary in 2020 without supporting single payer," Democratic pollster Celinda Lake said.
Some in the party disagree with the rush toward a new program on the heels of existing healthcare fights.
"Right now, I'm protecting the Affordable Care Act," Democratic House leader Nancy Pelosi, of San Francisco, said Tuesday, repeating her long-standing position that talk of a single-payer plan, which she supports in theory, remains premature. "None of these other things … can really prevail unless we have the Affordable Care Act protected."
Lake and other pollsters say there's an even more basic reality: Most voters have little idea of what single-payer would do and how it would do it. In one focus group, for example, a participant expressed frustration over what "single payer" healthcare was, Lake said.
"What does single payer mean? The only single payer is me," the focus group attendee said.
The label refers to a government program that would pay for and regulate healthcare for all Americans. It would replace the current system dominated by employer-supplied private insurance and supplemented by Obamacare's government-assisted individual insurance plans.
It also would affect Medicare, which covers those 65 and older, and Medicaid, the program for lower-income people and the disabled that was expanded under Obamacare and now covers about 1 in 5 Americans.
As Sanders alluded to, it would eliminate the need to pay premiums to insurers for coverage but would require a very large tax increase.
The fact that most voters aren't familiar with single payer could allow candidates who have endorsed it to define for themselves what they've signed onto. Then again, they will be defined by opponents as embracing the most extreme version.
"There's a lot of energy for single payer," said Bill Burton, a former Obama spokesman and party strategist. But at this point, the parameters of a bill are unknown, he said.
"It's an idea that people are supporting, not actual legislation."
Sanders will determine, in large part, how much flexibility his colleagues have. While he remains an independent, somewhat distant from the party whose nomination he sought last year, the Vermont senator has an unparalleled ability to draw in the young voters on whom the Democratic Party's future depends.
Last year, that ability came at the expenses of the party establishment and eventual nominee Hillary Clinton, with whom he clashed over healthcare.
Sanders argued that universal coverage was necessary both to protect Americans' health and to break what he called the "corrupt" control of the healthcare system by pharmaceutical companies and other interests.
Clinton countered that his plan "will never, ever come to pass."
Since the campaign — and the months-long, unsuccessful fight by Republicans to repeal Obamacare — things have changed.
A Pew Research poll in June found that the percentage of Americans favoring a single-payer plan had risen to 33%, five points higher than in January and 12 points higher than three years earlier. Two-thirds of Democrats younger than 30 favored a single government plan, as did 22% of young Republicans.
Sanders has said support for his plan should not be a litmus test for candidates, but some of his most loyal partisans disagree in words that conjure a coming fight.
"It's a litmus test," said RoseAnn DeMoro, the executive director of National Nurses United. "The Democrats hate it when I say that."
Any intra-party conflict will be piled upon the nervousness that defines every effort by either party to change the nation's healthcare system. The persistent problem: Although Americans often vote for change, they also fear it.
Vavreck said she was surprised at the quick shift among Democrats from defending Obamacare, which kept much of the insurance system in place, to fighting for what has been deemed a long shot.
"The idea that you go to the biggest, boldest idea seems to me an unusual way to make progress," she said. Sanders and other Democrats may have decided, she said, that "if you don't push for a foot, you never get an inch."
1:15 p.m.: This article was updated with quotes from Sen. Sanders' announcement.