Less than two months after the 2017 Republican push to kill Obamacare perished overnight on the Senate floor, more than a third of the Democratic caucus gathered in a much smaller room on Capitol Hill to take turns making the case for Sen. Bernie Sanders‘ new “Medicare for All” bill.
The Vermont independent had boosted single-payer health care plans before, but it had been a lonely enterprise. A previous iteration attracted no co-sponsors. This time, though, he was ringed by colleagues — among them, four of his future Democratic presidential rivals: Sens. Elizabeth Warren of Massachusetts, Kamala Harris of California, Kirsten Gillibrand of New York and Cory Booker of New Jersey.
The failed GOP coup united Democrats, for a least few heady weeks that summer, across ideological lines. Come 2018, House Republicans would pay dearly for their efforts, as Democrats campaigning on promises to protect and grow government-backed health care swept into the majority.
Their success in the midterm elections ratcheted up a simmering debate within the party over the path forward, with Democratic lawmakers from both chambers churning out piles of often-overlapping new plans. But it is Medicare for All, the most radical of the lot, that continues to roil the party as the 2020 presidential primary enters its stretch run to Iowa.
When Sanders rolled out the 2019 version of the bill, it had many of the same co-sponsors, including the four senators who became his 2020 opponents. But only Gillibrand — who qualified her support during a candidacy she ended on Wednesday — turned up for the event.
In the cauldron of a campaign — under pressure from skeptical voters, political rivals, donors and other interest groups –the fragile coalition that joined Sanders that day in 2017 has largely fractured. Only the Vermont independent, who has made Medicare for All the central theme of his second presidential bid, and Warren remain committed to the bill.
New plans and a new debate
Harris ultimately chose to push forward in late July with a new health care proposal. Her plan would grow Medicare over a decade on the way to universal coverage. But unlike Medicare for All, it would retain a role for the private insurance industry.
The California Democrat recently confessed what had become obvious from early on in her campaign.
“I support Medicare for All. But as you may have noticed, over the course of the many months, I’ve not been comfortable with Bernie’s plan, the Medicare for All plan,” Harris said during remarks at a fundraiser in the Hamptons. “And I’ll tell you why. And again, it comes back to listening.”
Back in August 2018, Harris had touted herself “the first Senate Democrat to come out in support of Bernie Sanders’ Medicare for All bill.” But in the time since then — as she entered the presidential race and began campaigning — she said voters she met on the trail and, specifically, union members had expressed their own misgivings. So Harris took heed and charted a different path from Medicare for All.
Her proposal was pilloried from the left and center. Former Vice President Joe Biden’s team — which has taken the more moderate stance of expanding the Affordable Care Act — called it a “have-it-every-which-way approach” that, because Harris has forsworn a middle-class tax hike to pay for it, meant she wasn’t being “straight” with voters.
Now, a month later, Harris spokesman Ian Sams told CNN the campaign was betting that — as Democrats dig in to the policies on offer — they would find both comfort and ambition in her vision.
“She’s focused on getting the right plan for people, not on pursuing ideology,” Sams said. “So let the chips fall where they may. We believe we have the best plan, and that when we message it and talk about it and when we get into the heart of this campaign, if people are really kicking the tires on these candidates, that voters are gonna agree with that.”
The challenges facing the Sanders campaign are different, but rooted in a similar, vexing question: What exactly do Democratic voters want?
There is a clear consensus among the party base in support of efforts to expand coverage and care — even Biden, an out-and-out Medicare for All opponent, wants to build on Obamacare with a government-backed public option. But the polling varies depending on how the questions are asked and the respondents’ understanding of the policies.
Sanders’ answer has been to broaden the question — and sharpen the conflict. His campaign views Medicare for All as a moral imperative, comparing it to past struggles like the civil rights movement. Any “half measure,” as Sanders so often puts it — especially one that would preserve the private insurance industry — amounts to capitulation.
“It’s really a value statement about who you stand with in this political and economic system. Do you stand with regular people or do you stand with the people at the very, very top? And so I think it is, appropriately, in many people’s minds a proxy for that, for where you stand in that larger fight,” Sanders senior adviser Jeff Weaver said.
Sanders’ success in pushing Medicare for All into the political mainstream — 57% of Americans said they favored it in a Kaiser Family Foundation poll from the month he entered the race — has put the debate into a new frontier. The policy is being taken seriously and, with that, has come under increasing scrutiny across the board. The Partnership for America’s Health Care Future, an insurance and pharmaceutical industry group, is ramping up its attacks. Even within the Democratic ranks, some labor leaders are amplifying their concerns.
Biden has seized on those worries.
“You’ve negotiated really hard for your benefits with your union with the employer. In my plan you get to keep it. You don’t have to give it up,” he told the Iowa AFL-CIO last week.
Earlier that morning, on August 21, Sanders unveiled his labor proposal. It focused on doubling union membership during his first term in office. But toward the bottom of the page was a new wrinkle: The transition to Medicare for All would now include a parallel provision guaranteeing that unions with employer health care plans would get to renegotiate their deals. The goal, according to the plan, was to be sure “all company savings that result from reduced health care contributions from Medicare for All will accrue equitably to works in the form of increased wages or other benefits.”
The new detail was cast as a U-turn or backtracking from Sanders by some rival campaigns. In fact, as his campaign quickly noted, the language of the bill had not changed. But the added inducement, forged in a bid to win broader union support, underscored the tricky politics ahead.
Warren, the only other top-tier candidate running on Medicare for All, has frequently said unions would play a key role in shaping the details of her own transition. The goal, she said in July, was to assure “that they’re made whole” in the bargain.
Though she has yet to unveil a specific mechanism for achieving that, a Warren aide told CNN this week that the campaign is talking with labor leaders about how unions with negotiated health care plans will be guaranteed a chance to rework their agreements during a Medicare for All transition.
Biden, meanwhile, appears content to poke holes in the loftier proposals while touting his own as the most feasible. His spokesman, Andrew Bates, called Obamacare “one of the most monumental progressive victories in a generation” and said Biden was committed to “protecting and building on it.”
“Whether they come from Republicans or Democrats, he will oppose any efforts to get rid of the ACA — and unfortunately, that’s exactly what Medicare for All would mean for the country,” Bates said.
Roadblocks up ahead
As much as the Democratic candidates’ plans differ, a Republican-controlled Senate headed by Majority Leader Mitch McConnell would pose similar challenges to them all.
The Kentucky Republican glories in his ability to smother progressive legislation and would likely view Biden’s plan the same way he does Medicare for All — as a bill with no future in the chamber he controls.
Even if the Democrats win back the Senate and presidency heading into 2021 while maintaining their House majority, the prospects for major new health care legislation remain complicated — especially if the legislative filibuster, which effectively requires 60 votes to move a bill, remains in place. Getting to 50 votes would be difficult too, given the number of Democratic senators who are either opposed to Medicare for All or currently uncommitted.
Warren has pledged to eliminate the filibuster if she’s elected. Sanders, when he rolled out the newest version of his Medicare for All bill, said he would do what it takes to get it passed — but, like Harris, has been more circumspect. Biden, too, has been open about his concerns over the knock-on effects of such a move.
It’s another debate sure to escalate over the coming months — one that could, in the final accounting, mean as much as the legislation now defining this primary.