During both nights of this week’s Democratic primary debate, the candidates squabbled over the ins and outs of their competing visions for Medicare-for-all, a health coverage system that would eliminate most private health insurance in America: Would they raise taxes on the middle class to pay for it? Would they allow for some sort of regulated private insurance? How would providers be paid?
On the second debate night, Sen. Kamala D. Harris (Calif.) said that “there will be a public plan” and “a private plan, under my plan for Medicare.” On the first night, though, Sen. Bernie Sanders (I-Vt.) made clear that his goal is single-payer health care, exclaiming, “It’s not a business!” and underscoring his view that “our job is to run a nonprofit health-care system.”
The leading contenders vying for their party’s presidential nomination did not agree on all the details, but in their disagreement was a subtle yet clear message: They have been thinking about these issues for a long time. They have big plans — and Republicans do not.
Yet when it comes to health care, the lack of plans, at least in the short term, is the Republican plan. Their strategy is simple: Let Democrats run on Medicare-for-all — and hope it backfires.
Trump has been promising to devise a GOP health-coverage plan for much of the year, in the hope of blunting Democratic momentum on the issue. In March, he tweeted, “The Republican Party will become ‘The Party of Healthcare!’ ” In a sit-down interview with ABC’s George Stephanopoulos in June, the president said: “If we win back the House, we’re going to produce phenomenal health care. And we already have the concept of the plan, but it’ll be less expensive than Obamacare by a lot.” But so far, Republicans have struggled to come up with much of substance.
Although Republican states are seeking to overturn the Affordable Care Act in the courts, and the Trump administration has made the unusual decision, as the executive branch, not to defend the law, the congressional GOP has effectively no backup plan for what to do if the lawsuit succeeds. Some conservative proposals exist, such as the Cassidy-Graham plan, which would have turned ACA funding into block grants to states, but so far, they lack congressional buy-in.
The president, meanwhile, is moving forward this week with an executive order to allow some drug reimportation from Canada, and may roll out more such initiatives over the next year, as part of a strategy Trump advisers have signaled is designed to push back against Medicare-for-all. But regardless of their merits, these sorts of White House micro-initiatives are unlikely to serve as an ideological or policy counterweight to something as transformatively ambitious and attention-grabbing as Medicare-for-all.
That is why Trump is set to make the Democratic plan the centerpiece of a speech next week, the goal of which will probably be to hang the least popular parts of their plan around Democrats’ necks. As one White House official told the Wall Street Journal, Trump is “going to indict and impugn the idea of Medicare for All.”
If history is any guide, that means a barrage of warnings about the perils of socialism and the ways in which Medicare-for-all would disrupt both private insurance and Medicare as we know it today. Trump has repeatedly derided Medicare-for-all as a socialist program, declaring in a USA Today op-ed last year that “The new Democrats are radical socialists who want to model America’s economy after Venezuela.” Medicare-for-all, he wrote, would end Medicare as we know it, take away choice from today’s seniors and serve as a prelude to a government takeover of much of the rest of the economy. That message dovetails with the rhetoric Trump used in his June kickoff rally, when he railed: “A vote for any Democrat in 2020 is a vote for the rise of radical socialism and the destruction of the American Dream.”
Trump’s bring-it-on approach mirrors House Republicans’ exuberance earlier this year when Democrats announced they would hold hearings about single-payer health care. “We’re going to pull the curtain back on Medicare for all so the American people can actually assess it,” Rep. Kevin Brady (R-Tex.), told Politico in February. Republicans think they are ready to have this fight, and they think they will win it.
They may well. While polls have shown that Medicare-for-all is popular insofar as it is a promise of government-guaranteed health care, it becomes unpopular when people are informed about the potential costs: Earlier this year, in a Kaiser Family Foundation tracking poll, when respondents were asked whether they would favor or oppose Medicare-for-all, support dropped from above 60 percent to below 40 percent based on being told it could result in higher taxes, delayed medical treatments or the elimination of private health insurance — all of which are plausible outcomes, given international experience with single-payer systems. #M4A is popular right up until people find out how it works.
There are risks for the GOP, as well: Vigorously defending today’s Medicare, the nation’s largest government-run health care program, while simultaneously attacking government-run health care, requires contortions that would challenge even the most capable performer at Cirque du Soleil because depending on your definition, Medicare already is a socialist program. The hearings on Medicare-for-all that House Republicans were so excited about do not seem to have slowed the idea’s momentum. If anything, this week’s debates suggest it is defining the 2020 primary race.
Nor does it solve the looming question of what to do if the lawsuit against the ACA somehow succeeds. But vilifying Medicare-for-all does focus public attention away from that lawsuit and its potential effects, reducing the power of the most effective argument Democrats made during last year’s midterms, that Republicans oppose preexisting conditions regulations.
Throughout the past decade, when symbolic health law repeal votes were held almost ritualistically by congressional Republicans, the GOP has been more comfortable opposing Democratic health care ideas than proposing its own. In the long term, the nation’s politics — not to mention its health care system — are almost certainly worse off because Republicans have largely ceded this policy territory to Democrats. But as a short-term political strategy, simply opposing Medicare-for-all may turn out to be more effective than any plan Republicans could devise on their own.