What the Presidential Candidates Aren't Telling You About Medicare For All

AP Photo/Steven Senne

Senator Bernie Sanders approaches a podium during a campaign stop in Concord, New Hampshire. 

While the essential positions of the two major parties on issues don't change much, every once in a while a party will have to decide not just what it believes in on a particular subject, but exactly what it wants to do about it when it takes power. The more complex the issue is, the longer that process can take. Right now, Democrats are debating where they should go on health care—one of the most critical and knotty policy challenges that exists—but they're doing it faster than they've ever had to before, even as the solutions they're moving toward are more ambitious than anything the party has previously embraced.

In the process, they may be gliding past one of the most critical questions they'll face if they actually get the chance to pass Medicare For All, or whatever it will ultimately be called: not just which policy would be preferable if it became law, but how they can get it to become law. A bunch of politicians aren't demonstrating that they've thought through the politics of what they're committing themselves to.

To understand what I mean we have to go over a bit of health care history, beginning with the failure of the Clinton health care plan in 1994, an effort that was overseen by Hillary Clinton. Although many people now think of both Clintons as timid incrementalists, their plan was sweeping, disruptive, and difficult to explain—though in many ways it resembled the Affordable Care Act that Barack Obama would pass in 2010. Most of all, it engendered not only united opposition from Republicans but furious pushback from insurers and others in the health care industry, who aired ads featuring a middle-class couple ("Harry and Louise") worried that they'd lose what health security they had if the law were passed. A year after it was introduced, the bill was withdrawn without ever coming to a vote (the Prospect's Paul Starr, who worked on the effort in the Clinton administration, tells the story of its failure here).

It's the next part of the history that's critical to our story. After the Clinton plan was withdrawn, Democrats went back to the drawing board, spending the next decade and a half thinking both about health care policy and about health-care politics. This was a debate that took place among policy wonks, political professionals, and elected officials, playing out over those years both in private and in public.

So by the time we reached the 2008 election, the health-care plans offered by all three leading candidates for the Democratic nomination for the presidency—Barack Obama, Hillary Clinton, and John Edwards—were remarkably similar. There were differences in the details, but they all embraced an expansion of government health coverage, subsidies for people with low or moderate incomes, and increased government regulation of insurance.

It wasn't because the three had some kind of personal mind-meld. They were all reflecting the consensus that had emerged within the party, that this was the path for Democrats to follow on health-care reform. And one of the core pieces of that consensus was that avoiding another "Harry and Louise" debacle was critical. In order to get reform passed, you couldn't just fight the nearly infinite resources of the insurers, pharmaceutical companies, hospitals, and doctors, because if you tried, you'd lose. You had to co-opt them, convince them to support the Democratic reform, or at least not fight too hard against it.

Which was a key part of the year-long effort to assemble the ACA after Obama took office. His administration worked to win over insurers, for instance, by offering them a bargain: If you accept greater regulation, you'll get more customers as we bring private insurance to millions of people who don't have it. While there were moments when the insurers looked ready to abandon the ACA, in the end they stayed on board and the law passed without a single vote to spare in the Senate.

Whatever you might think about the ACA, that 15-year process did what it was supposed to: It arrived at a policy solution the party could live with, and it successfully dealt with the opposition so that the bill could be passed.

Now let's fast-forward to today. Democrats are going through the same process, but it's one that really only began once they moved from defending the ACA against legal and legislative attacks to debating the next phase of Democratic reform. The last major event in the defense of the ACA was the defeat of the Republican attempt to repeal it, which happened in July 2017, less than two years ago. There were 14 years between the defeat of the Clinton plan and the 2008 election; there will have been just over three years between the defeat of GOP efforts to repeal the ACA and the 2020 election.

But since 2017, Democrats have been talking about health-care policy to the almost total exclusion of health-care politics.

In that discussion you can see how the successful ACA traumatized Democrats just as surely as the failure of the Clinton plan did. They worked so hard, fought against a torrent of Republican misinformation ("Death panels!"), spent untold effort explaining an intricate law that left most voters puzzled, and had to defend it from one ridiculous lawsuit after another—and it was a law they weren't all that crazy about in the first place. Ask any Democrat what they think of the ACA, and they'll respond wearily, "Look, I know it's not perfect, but it did a lot of good."  

Shaped by that experience, many if not most Democrats are done with trying to compromise with Republicans or support half-measures. They want universal coverage and they aren't going to settle for anything less. So single-payer plans like those offered by Bernie Sanders and Representative Pramila Jayapal are being taken more seriously than ever, and nearly every Democratic presidential candidate says they support "Medicare For All," even if that has become a squishy term that can mean many things, including systems that would maintain a role for private insurance and where enrollment in a government plan is voluntary.

Eventually, every presidential candidate will have to put forward a detailed plan. Once again, the differences between them are likely to be real but small, or at least they'll be able to fit into one of two camps: single-payer plans like Sanders's, and others that allow any American to join a government insurer if they choose, whether it's Medicare, Medicaid, or something new. All will represent a profound change in the American health care system.

If, that is, they can pass Congress. And that's the thing none of the candidates are really talking about. If we're going to sharply reduce or even eliminate the role of private insurers, they are not going to be co-opted. If we're going to rein in soaring drug costs, the drug companies will not agree. If we're going to control prices, which is the real key to bringing down the absurd amounts we pay for health care, doctors and hospitals will not go along.

So how is this going to work? Democrats have a chance to win control of the Senate in 2020, but they won't get 60 votes. So can they pass a health care overhaul through reconciliation, or are they going to have to eliminate the filibuster?

Even if they do that, it could be a longshot. When the hospital industry's lobbyists tell your member of Congress that the local hospital—the biggest employer in her district—will go out of business if Medicare For All is passed (regardless of whether that's true), will she still be willing to vote for it?

Those kinds of questions are hard to answer, but so far the presidential candidates have barely even tried. Maybe that shouldn't be surprising; candidates usually claim that things are going to be easier than they turn out to be. They know that voters aren't exactly eager to hear a candidate say, "Here's the great future I'm promising you, but to be honest, odds are against us getting it through Congress."

So it's entirely possible that we'll get to November 2020 with a newly elected Democratic president who promised a radical overhaul of the American health-care system but never grappled with the intense opposition such an effort is going to encounter and how it might be overcome. I sure hope they're thinking about it in private, and they have some idea of how to get it done.