Despite the early focus on broad reform plans, polling shows that reducing out-of-pocket costs is Americans’ top healthcare policy concern nationwide. A Kaiser Family Foundation poll released Feb. 21 showed that 27% of respondents who named healthcare as an important issue chose costs as their top concern, followed by 25% who cited increased access to care. A Morning Consult/Bipartisan Policy Center poll released in January showed that 64% of respondents nationally said lowering out-of-pocket costs was one of their top three healthcare priorities, followed by lowering prescription drug costs at 57%. The KFF poll also showed that 62% of Democrats surveyed would support either a public insurance option or a single-payer system.
Candidates could pivot in the general election to describing how their large-scale plans would impact voters’ pocketbooks. But the debates so far have not showcased those differences, said National Nurses United Assistant Director Kelly Coogan-Gehr. Medicare for All as proposed by Sen. Bernie Sanders (I-Vt.) would eliminate copayments, premiums and deductibles, while public option proposals pitched by such moderates as former Vice President Joe Biden, former South Bend, Ind., Mayor Pete Buttigieg and Sen. Amy Klobuchar (D-Minn.) would not necessarily do so. Medicare for All would cost much more than a public option, but could reduce administrative bloat.
Moderates have also used the debates to frame Medicare for All as a threat to consumers losing access to private insurance options, an especially sensitive issue with labor unions. “I keep listening to the same debate, and it is not real. It is not real, Bernie, because two-thirds of the Democrats in the Senate are not on your bill, and because it would kick 149 million Americans off their current health insurance in four years,” Klobuchar said in a debate on Feb. 7.
These criticisms come even as Democrats in Congress are clobbering the Trump administration and Republican attorneys general for pursuing a lawsuit that would invalidate the entire Affordable Care Act and cause an estimated 20 million people to lose their coverage.
Republicans have seized on the narrative that Americans with private insurance would be kicked off of their plans under Medicare for All to deflect criticism that its lawsuit to strike down the ACA could lead to mass coverage losses for individuals who get coverage through health insurance exchanges or Medicaid expansions.
“The leading candidate for the Democratic nomination for president of the United States is proposing to do away with all private health insurance, including the Affordable Care Act, and replace it with Medicare for All,” Sen. John Cornyn (R-Texas) said during a Senate Finance Committee on Feb. 13. Cornyn is running for re-election this year.
But the specter of uncertain coverage changes could allow Trump to advocate for incremental policies to lower healthcare costs, though many of his administration’s banner drug-pricing policies have stalled, been struck down by the courts, or have not gone into effect.
“The focus on this big systemic reform has drowned out discussion of everyday concerns like drug prices and out-of-pocket costs,” Levitt said. “This leaves an opening for Trump to appeal to voters’ pocketbooks without the scariness of upending the entire system.”
Blendon agreed that Democratic candidates may be overestimating voters’ appetite for systemic change in the healthcare system.
“In the general election, if the economy keeps going well, voters will not be focused on revolutionary change. They will want change to their bills, deductible, and the cost of EpiPens, and they are going to be focused on something much narrower for that,” Blendon said.
The healthcare industry is staunchly opposed to a single-payer healthcare system, and healthcare executives have so far overwhelmingly donated to campaigns of moderate Democrats who stop short of supporting Medicare for All.
While Medicare for All would certainly disrupt the healthcare industry, Manatt Health Managing Director Chiquita Brooks-LaSure said the industry and consumers could have much to lose if the ACA is invalidated by the courts.
Even a Sanders presidency may not be cause for widespread panic by the healthcare industry, as any large-scale reform would have to pass through a Congress that may not be controlled by Democrats.