One of the main weaknesses of the standard Presidential-debate format in American politics is that it can be extraordinarily hard to delve deeply into any particular issue. Format aside, of course, it is often not in the interest of the candidates to do so. Yet, Thursday night’s debate featured a surprisingly robust discussion of the policy at the heart of the divide within the Democratic Party today: Medicare for All. It began with a question from Savannah Guthrie to Bernie Sanders, about whether he would raise taxes on the middle class to pay for his policy agenda, which of course includes Medicare for All.
“We have a new vision for America,” he responded. “And, at a time when we have three people in this country owning more wealth than the bottom half of America, while five hundred thousand are sleeping out on the streets today, we think it is time for a change. Real change. And, by that, I mean that health care, in my view, is a human right, and we have got to pass a Medicare for All, single-payer system. Under that system, by the way, the vast majority of the people in this country will be paying significantly less for health care than they are right now.”
Guthrie repeated her initial question: Would he increase taxes on the middle class or not?
“People who have health care under Medicare for All will have no premiums, no deductibles, no co-pays, no out-of-pocket expenses,” he explained. “Yes, they will pay more in taxes but less in health care for what they get.”
For some time now, surveys have shown strong support for Medicare for All, not just among Democrats but among the general electorate. But a recent survey from the Kaiser Family Foundation found considerable confusion about what the policy entails. They found that, although fifty-six per cent of Americans were supportive of “a national health plan, sometimes called Medicare-for-all, in which all Americans would get their insurance from a single government plan,” sixty per cent would oppose such a plan if it raised taxes for most Americans. Kaiser also found that fifty-eight per cent of Americans would oppose Medicare for All if it eliminated most private insurance, which Sanders’s plan would essentially ban. In fact, sixty-seven per cent of those who said they supported Medicare for All also said they believed that such a plan would allow them to keep their current insurance, which would not be the case for those with private insurance under Sanders’s plan.
The plan that most Americans appear to actually support is an optional Medicare or Medicaid buy-in, which, according to the Kaiser Family Foundation, is about twenty points more popular than Medicare for All among Americans. These are the options favored by the candidates who are looking to establish themselves as moderates in the Democratic race, including Michael Bennet, who was also on the debate stage last night.
“Health care is a right,” he said. “We need to get to universal health care. I believe the way to do that is to finish what we started with Obamacare,” by creating a public option that families can choose over private offerings. For those who choose the public option, Bennet said, it “would be like Medicare for All.”
A bit later, Pete Buttigieg agreed. “Look, everybody who says ‘Medicare for All,’ every person in politics who allows that phrase to escape their lips, has a responsibility to explain how you’re actually supposed to get from here to there,” he said to applause. “Here’s how I would do it. I would call it Medicare for All who want it. You take something like Medicare, a flavor of that, and make it available on the exchanges. People can buy in, and then, if people like us are right, then that will be not only be a more inclusive plan but a more efficient plan than any of the corporate answers out there.”
The debate stage also included Joe Biden, a representative of the Administration that built the health-care exchanges. “The fact of the matter is that the quickest, fastest way to do it is build on Obamacare, to build on what we did,” Biden said. “And, secondly, to make sure that everyone does have an option. Everyone, whether they have private insurance or employer insurance, or no insurance, they could, in fact, buy into the exchange to a Medicare-like plan.”
Sanders wasn’t having any of this. “I find it hard to believe,” he said, “that every major country on earth, including my neighbor fifty miles north of me, Canada, somehow has figured out a way to provide health care to every man and woman and child, and in most cases they’re spending fifty per cent per capita what we are spending. Let’s be clear—let us be very clear—the function of health care today, from the insurance and drug company perspective, is not to provide quality care to all in a cost-effective way. The function of the health-care system today is to make billions in profits for the insurance companies.”
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Sanders’s case for his maximalist vision of universal health care—an insurance system unlike any other in the world, that is totally public, totally free of premiums, free of deductibles, and free at the point of service—has always been primarily a moral case. It might be less expensive to implement a buy-in plan that retains private insurance. But Sanders firmly believes and argues that health insurance should not be a for-profit business at all. And he is betting that Americans will be willing to trade their current insurance plans for the security of knowing that their health care will be entirely free and that they won’t ever have to switch plans again.
It’s unclear if, after several more months of public discussion about the details of his plan, voters will see things as simply Sanders does. But his persistence, and the resonance that his vision has had with Party progressives and activists, have already moved the Party and the rest of the field in his direction, both substantively and rhetorically. Even those who don’t support Sanders’s plan in full have taken to calling their positions Medicare for All or something similar. During Wednesday’s debate, Elizabeth Warren said straightforwardly for the first time that she, like Sanders, would eliminate private insurance to establish Medicare for All.
During Thursday night’s debate, Lester Holt asked all the candidates whether they would do the same. Only two raised their hands—Sanders and, surprisingly, Kamala Harris, who expressed support for eliminating private insurance in a CNN town hall, in January, only to walk back her comments shortly afterward. In her remarks Thursday, however, she seemed to give a stirring defense of Sanders’s position.
“The reality of how this affects real people is captured in a story that many of us have heard and that I will paraphrase,” she said. “Any night in America, a parent who’s seeing that their child has a temperature that is out of control calls 911—‘What should I do?’ And they say, ‘Take the child to the emergency room.’ And so they get in their car, and they drive, and they’re sitting in the parking lot outside of the emergency room looking at those sliding glass doors, while they have the hand on the forehead of their child, knowing that if they walk through those sliding glass doors, even though they have insurance, they will be out a five-thousand-dollar deductible, five thousand dollars if they walk through those doors. That’s what insurance companies are doing!”
But, after the debate, Harris and her team told reporters that she did not support eliminating private insurance, and that she had believed Holt was asking whether candidates would support, in their own personal lives, trading private insurance for government insurance—a bizarre misreading of a straightforward and important question that had been asked of the candidates the night before, and repeatedly on the campaign trail. Harris’s vacillations seem indicative of the risks for candidates who are looking to match Sanders’s clarity of rhetoric, without a full commitment to substance. It is another example, too, of how Sanders has forced the candidates to establish policy distinctions among themselves in a race that could have easily been focussed entirely on the evils of Donald Trump. Democratic voters clearly expect more. Whether they will come to demand as much as Sanders is offering remains to be seen.