Sorting Through What the Democratic Candidates Really Think About 'Medicare-For-All'

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Senator Kamala Harris speaks at her first presidential campaign rally at Oscar Grand Plaza in Oakland, California. 

When I was 24 years old, with field-grunt positions on a couple of campaigns under my belt, I went to work for a political consulting firm where one of the first things I was taught was that getting too specific about policy was deadly for candidates. The trouble with putting out a bunch of white papers was that the more detailed you got, the easier it would be for voters to find something in your proposals they didn't like. And all it took was one disagreement for a voter to turn away and support another candidate who hadn't said anything they objected to. The safer path was to lay out broad principles on policy without getting too specific.

It's hard for a presidential candidate to follow that advice, particularly on an issue that the primary electorate cares deeply about. But so far, the Democrats running for president (and those thinking about running who haven't yet pulled the switch) are at the very least keeping their options open on many subjects, especially the one that looks to be the most important policy argument of the 2020 primaries: health care, or more specifically, Medicare-For-All.

Before we get to what the candidates are saying and will be saying, a word about that descriptor. Not that long ago, when liberals were asked what kind of health system they'd prefer, the words "single-payer" became the most common answer. The problem was that a true single payer system, in which everyone is covered by a government plan and there's little or no role for private insurance, exists in only a few places like Taiwan, while there are many other systems that provide universal coverage but include a role for (closely regulated) private insurers.

As it became clear that many liberals were open to universal systems that weren't necessarily single-payer, liberals cast about for a different term to describe what they were for. "Universal coverage" might have been a contender, but for some reason it never caught on. Instead, "Medicare-For-All"—capitalizing on the enormous popularity of Medicare—became the thing every Democrat began to say they're for.

To the dismay of the wonkish or pedantic (or both), Medicare-For-All is now being used to describe a variety of different kinds of systems with significant differences. At this point, though, we may have no choice but to live with it, particularly because it seems so popular among the Democratic presidential candidates who will be at the center of this debate.

And as far as they're concerned, getting too specific could indeed be dangerous. Kamala Harris, for instance, did a town hall on CNN last week, and was asked about whether she really supported eliminating private insurance companies. That is what would happen under Bernie Sanders's Medicare-For-All plan, which Harris has cosponsored. She affirmed the idea, describing the difficulties private insurers create and saying "Let's eliminate all that, let's move on." But within a day, her aides were telling the press that Harris is open to multiple paths to reform, even if she still preferred true Medicare-For-All.

That's probably why Harris is a cosponsor not just of Bernie's plan, but also of this plan and this plan and this plan, all of which try to expand coverage through the government in different ways without eliminating private insurance. She may be hedging her bets, but it also appears that she's been happy to sign on to any proposal that sounds better than what we have now.

And there's nothing wrong with that. In fact, all four of the senators currently running for president—Harris, Elizabeth Warren, Cory Booker, and Kirsten Gillibrand—cosponsored Bernie Sanders's bill, but none of them seems to look at it the way Bernie himself does, that eliminating private insurance is the only solution to our health-care problems and anything else would be inadequate.

Unfortunately, that means that when someone says "Medicare-For-All," it's hard to know precisely what they mean. At a minimum they may mean that they want any American to at least have the option to join Medicare, or another government insurance plan, if that's what they'd prefer.

That question of choice is absolutely essential to this debate, both substantively and politically. Allowing people (or businesses) to choose to join Medicare but not requiring them to do so would make for a much less disruptive transition, even if over time the role of private insurers grows smaller as more people switch to the government plan (which is likely to be more affordable).

Just as important, Americans respond far more positively to the idea of opening up Medicare to those who want it than to the idea of moving them from their current plan to Medicare whether they want to or not. Don't forget, over 150 million Americans currently have employer-sponsored coverage, and people fear change whether the change will work out better for them in the long run or not.

Which is why the safest path for a presidential candidate to take is probably to offer the broadest possible interpretation of Medicare-For-All, applying it to a variety of ideas that may not be precisely compatible with one another. The first step for some of them is to say that though they cosponsored Sanders's bill, they don't necessarily think private insurance has to be eliminated right away, if at all. That seems to be Harris's position, it's what Booker has said, and it's what Warren says, too. Gillibrand describes a voluntary buy-in as a way to eventually get to a single-payer system.

Because it's so early in the race and none of the candidates has produced detailed campaign proposals on just about anything, at this point they can be pretty vague. But as the race proceeds, voters are going to demand more specificity, particularly since this issue is so close to the hearts of the Democratic base and will be such a critical priority for the next president. Right now they can say they're for multiple different ideas, and put them all under the umbrella of "Medicare-For-All." But probably not for long. 

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