'Medicare for all' proves to be tricky issue for Democrats

“Medicare for all,” the concept of expanding Medicare into a single payer for seniors and non-seniors alike, has divided the House Democratic caucus ahead of November's midterm elections.

Single-payer advocates continue to push the idea, but Democratic strategists hope the issue remains fringe at best, making it fodder for debate in the primaries but unlikely to define Congress' healthcare platform for 2020.

An April poll on the subject found a slim majority—51% of the public—favors a single-payer system, according to the Washington Post and Kaiser Family Foundation, which conducted the survey.

As far as the actual vote goes, looking district by district, the lead goes away, operatives say. Most Americans get coverage through their employers, and those people are mostly satisfied with the way things are.

The baby boom generation also is opting for Medicare Advantage coverage, making it difficult for members of both political parties to believe a large-scale amorphous shift to an expanded version of Medicare can ever be a political winner. Both Republicans and mainstream Democrats are messaging accordingly.

“The American people don't have an appetite for scrapping everything and starting over,” said Brad Woodhouse, who as campaign director of the liberal advocacy group Protect Our Care is overseeing a massive campaign effort across 14 mostly swing states. “That applies to scrapping the Affordable Care Act for single-payer and scrapping the Affordable Care Act for repeal.”

One insurance industry lobbyist said he believes the “Medicare for all” message will continue to gain momentum because its simplicity appeals to people after the last few years of turmoil over the individual market. Democrats may be pushed to the left before voters understand the complexity of a single-payer plan, he added, and Republicans who don't want to touch repeal-and-replace again may find themselves on the defensive pushing back against “Medicare for all.”

Adding fuel to the debate, an economist from the libertarian Mercatus Center of George Mason University predicted massive reductions for providers as the sole restraint to the healthcare costs spurred by the “Medicare for All” plan put forward by Sen. Bernie Sanders (I-Vt.). The white paper calculated the plan would cut provider payments by more than $380 billion in the first year and nearly $660 billion in 2030.

Ceci Connolly, president of the Alliance of Community Health Plans, compared today's inter-party debate to the massive public backlash against the continuous double-digit premium increases of the late 1990s. But Connolly says the tone of the discussion has changed. “That era was very different than where we are today, when we have small but vocal groups with a very sharp opinion of what they want from the healthcare system,” she said. “I don't see that opinion broadly across the electorate—probably just within the base of the two political parties.

Democratic strategists had hoped to avoid much discussion of creating a single-payer system, fearing it would hurt the party as it angles for a majority in at least one branch of Congress. In the wake of the GOP's failed measure to repeal Obamacare, Democratic operatives saw an opportunity and urged incumbents and challengers to attack Republicans and the Trump administration for its acts of ACA sabotage.

Woodhouse cited the Trump administration's recent refusal to defend the ACA in a Texas federal court, along with the nomination of Brett Kavanaugh to the U.S. Supreme Court, as gifts the Democrats needed to galvanize voters around healthcare. Early primary elections favored Democrats who ran on shoring up the ACA and promoting the so-called public option.

But then progressive Democratic candidate Alexandria Ocasio-Cortez defeated longtime Rep. Joe Crowley (D-N.Y.), a rising star in the party who was considered a shoo-in as next Democratic speaker. A former campaigner for the presidential bid of Sanders—the “Medicare for all” torchbearer—Ocasio-Cortez is now criss-crossing the country to campaign for fellow progressives.

Often joined by Sanders, Ocasio-Cortez is calling for the creation of a single-payer system, with mixed success. She pushed hard for progressives running on “Medicare for all,” but Brent Welder, running for GOP Rep. Kevin Yoder's Kansas seat, and Abdul El-Sayed, running for Michigan governor, both lost. Welder lost by about 2,000 votes and El-Sayed by a margin of 21 percentage points. Those losses, however were followed by wins by two single-payer supporters, Rashida Tlaib of Michigan and Ilhan Omar of Minnesota.

But “Medicare for all” fever had already hit the House. Shortly before lawmakers left Washington for August recess, Rep. Pramila Jayapal, a Democratic freshman from Washington state, launched the 60-plus member Medicare for All Caucus. Her explicit goal is to write substantive single-payer policy over the next two years in time for the 2020 election. Significantly, several in the crowd of potential contenders in the 2020 primary signed onto Sanders' “Medicare for all” legislation: including Democratic Sens. Kamala Harris of California, Cory Booker of New Jersey, Elizabeth Warren of Massachusetts and Kirsten Gillibrand of New York.

In a burst of drama, Rep. Keith Ellison (D-Minn.), the lead sponsor on the House single-payer bill, suggested progressive groups should call out Democratic lawmakers who don't back “Medicare for all.” “We need to run ads pointing out to constituents people who are not on the bill,” Ellison said at a single-payer conference last month, according to the Star Tribune in Minneapolis.

This rankled Rep. Betty McCollum, a fellow Democrat from Minnesota. McCollum's office did not respond to a request for comment for this story, but in a statement to the Star Tribune the lawmaker criticized Ellison's comments. “Mr. Ellison's rhetorical attack on Democrats fighting to gain control of the U.S. House is extremely disappointing, especially since he's quitting Congress and abandoning his own legislative effort,” McCollum told the newspaper.

Other House Democrats want to slow down the messaging war. “For each member, they really have to think about it on a district basis,” said Democratic Rep. Marc Veasey who represents a district in Dallas-Fort Worth that has one of the lowest insured rates in the country. “Everybody wants to nationalize everything, but the fact of the matter is that everyone needs to figure out how to address this. I think everybody's concerned about healthcare.”

Rep. Raul Ruiz (D-Calif.), a physician who sits on the House Energy & Commerce Committee, offered a similar sentiment when asked whether the “Medicare for all” message could be detrimental for Democrats. “I think we have to be very cautious on how we achieve universal care because if we don't get it right, it's not going to come up again for another century,” Ruiz said.

On the state level, legislatures and governors are wading into the minefield of industry opposition with a span of measures, including single-payer proposals. This could offer a glimpse of what the fight to come would look like should a “Medicare for all” coalition rally around a detailed plan.

One major point of contention centered on a California proposal that moved in the universal payment direction through an all-payer model. The bill by state Democratic Rep. Ash Kalra would have moved California's providers to an all-payer rate to be set as a percentage of Medicare by a special commission. Backed by patient advocates and labor unions who decry how healthcare costs are cutting into wage growth, the measure drew tremendous opposition from industry groups, especially hospitals that alleged the bill would cut provider pay by $18 billion in the first year alone.

The legislation never got passed by a committee, but a spokesperson for Kalra said he would likely introduce it again next year.

Legislators in New York and California both introduced single-payer bills, and Democratic gubernatorial candidates from California to Michigan to Massachusetts are also calling for single-payer, absent much detail.

It isn't clear how far states can go under the Trump administration. CMS Administrator Seema Verma took aim at “Medicare for all” in a speech at the Commonwealth Club in California, saying the agency would likely deny single-payer waivers. “It doesn't make sense to waste time on something that's not going to work,” she said, citing the cost of the program and Medicare's pending insolvency.

If Democrats take control of the House, or even both chambers of Congress, they could serve mainly to block Trump's moves. While mainstream Democrats say they want to stabilize the ACA, Trump has in the first half of his term worked to reduce the law's role, promoting the use of short-term plans and association health plans. The GOP-majority Congress has delayed and repealed Obamacare taxes including the individual mandate.

“Medicare for all” proponents want to fine-tune their message for 2020, Connolly said, but she'd prefer Congress to focus on correcting the existing system.

Similarly, liberal policy advocate Woodhouse said it would be more effective to support correcting the ACA's flaws. “If the point is to maintain what people have and strengthen it, and if that's where the American people seem to be, the most effective political argument for Democrats is to expose Republicans for wanting to rip away healthcare for millions of people,” he said.