Like an oasis shimmering before parched travelers in a sunbaked desert, “Medicare for all” holds a powerful allure for Democrats. It’s a clear concept based on a beloved program, offering to achieve the long-standing goal of universal health insurance. It will be hard for any Democrat running for president to reject the idea.
Sen. Kamala Harris made that clear when she not only endorsed the idea but also called for abolishing private insurance entirely. “Let’s eliminate all of that,” she said. By staking out a bold position so early in the campaign, she put pressure on other candidates to meet or raise her on the issue of single-payer, government-provided coverage.
The idea was already approaching party orthodoxy. Sen. Bernie Sanders ran for president on it in 2016 and may again in 2020. He would have company. Sens. Elizabeth Warren, Cory Booker and Kirsten Gillibrand are co-sponsors, along with Harris, of Sanders’ legislation. Former Housing and Urban Development Secretary Julian Castro is on board. A House version won the sponsorship of most Democrats, including presidential candidate Tulsi Gabbard.
All that happened before the rise of Rep. Alexandria Ocasio-Cortez, another supporter. Dylan Matthews wrote in Vox, “Soon no Democratic leader will be able to oppose single-payer.” That was in September 2017, and “soon” may already be “now.”
But like many an oasis, this one is a mirage. The broad conversion of Democrats to the single-payer model stems from their bitter experience with the Affordable Care Act, aka Obamacare. It was a market-oriented approach that retained a primary role for private insurance, strongly resembling a Massachusetts program enacted under a GOP governor named Mitt Romney. Yet Republicans in Congress universally demonized it as a radical socialist scheme.
The conclusion most Democrats reached is that moderation in pursuit of universal coverage is a vice. If you’re going to be portrayed as engineering a complete government takeover of health insurance regardless, they decided, you might as well go all the way.
That’s the wrong lesson. The ACA was an incremental, cautious program to provide insurance to more people, falling short of universal coverage. Yet the prospect of significant change was enough to make voters susceptible to shameless fearmongering. Over the seven years after it became law in 2010, according to Kaiser Family Foundation surveys, a plurality of Americans consistently took an unfavorable view of the program.
But when Donald Trump became president and Republicans gained control of Congress, they set about keeping their promise to repeal Obamacare. At that point, sentiment abruptly shifted. In February 2017, Kaiser found, 48 percent of Americans had a positive opinion of the ACA, and only 42 percent disliked it — and it has retained its popularity ever since.
The lesson is that when it comes to health care, Americans harbor a deep suspicion of any major change. They distrusted the ACA from the start because they feared it would cost them more, reduce the quality of care or deprive them of their existing policies.
But when Republicans tried to repeal the law, that aversion to change suddenly became the ally of Obamacare. However imperfect what they had was, voters worried that a replacement would be even worse.
Harris’ intention to get rid of private insurance will feed this fear. Americans rightly didn’t believe Barack Obama when he said, “If you like your health care plan, you can keep it.” When Harris says that people who like their health care plans will not be able to keep them, voters will believe her, to her detriment. Democrats can promise that “Medicare for all,” however it is defined, would be an improvement over the status quo, but millions of people with private coverage will figure they are about to get the shaft.
Single-payer coverage could generate even broader opposition than the ACA did, argues Lanhee Chen, a research fellow at Stanford’s Hoover Institution. When 30-year-olds hear the term “Medicare for all,” they may hope they’d get something better than what they have. But 70-year-olds will assume they’d get something worse. “It’s certainly possible that seniors will view ‘Medicare for all’ as cutting into the benefits they receive,” he told me.
At the moment, by preserving Obamacare, Democrats have aligned themselves with public sentiment. If they insist on promising “Medicare for all,” they will find themselves up against the perennial attitude of Americans about their health insurance and health care system: It’s lousy, and don’t you dare change it.