The 2020 Democratic presidential campaign kicked off strong with back-to-back political debates in Miami, Florida. This year’s debate saw an unusually large number of primary candidates (24, according to CBS News); however, only 20 of the candidates were eligible to participate. Over the course of the two-night event, half of the candidates faced off during the first night, while the other half eagerly awaited their turn at the podium on the second night. Moderators posed a series of questions on a wide variety of subjects; however, it was the topic of healthcare that dominated the post-debate analysis. More specifically, it was the expansion of single-payer coverage or “Medicare-for-All” that became the hot button issue of the debate.
The concept of a single-payer coverage system has major implications for Federal healthcare spending, including the proposed bills currently before Congress that seek to expand public healthcare coverage. The spectrum of the suggested plans ranges from single-payer, excluding private plans, to options that permit individuals to choose between public and private insurance. The future of these bills depends on the outcome of the 2020 presidential and congressional elections.
Overhaul or Incrementalism?
Among the Democratic hopefuls, there was almost 100 percent support for at least some form of expansion of public healthcare financing. Senator Bernie Sanders of Vermont introduced the Medicare for All Act of 2019 (S.1129), which would replace all private insurance, Medicaid, Medicare and CHIP with a tax-financed plan that would cover all costs, including premiums and cost sharing. Several candidates on the stage with Sen. Sanders co-sponsored this bill or similar legislation. In response to the torrent of criticism aimed at the Sanders plan by President Trump, the Senator referenced poll results that showed virtually all Democrats leading President Trump in an election where Medicare for All is predicted to become a major issue.
Candidate Joe Biden, perhaps understandably, supports building on the Affordable Care Act (Obamacare), which was enacted during his own vice-presidential administration. Biden argued that this incremental approach would be the quickest and easiest pathway to universal healthcare coverage. This may be a wise primary election strategy for the former Vice President, as 80 percent of registered Democrats consistently have favorable opinions of Obamacare.
Some of the candidates stressed the significant disparity between voters in favor of private coverage versus those in favor of expanding public financing — the former being the majority. Other candidates spoke to the impracticality of eliminating private insurance altogether. Former Maryland Congressman John Delaney, addressing Democrats in general, warned that sweeping away the private option could cost the entire party the White House in 2020.
The Case for Moderation
Mayor Pete Buttigieg of South Bend, Indiana, articulated a more moderate option of “Medicare-for-All-Who-Want-it,” suggesting that if the plan appealed to large numbers of Americans, it would eventually replace private health insurance. Others argued for systems closer to those of Canada and the United Kingdom, where citizens have the option of purchasing private insurance to supplement the public program. Such a plan would be comparable to the supplemental benefits that are currently available to Medicare recipients.
The high-cost of healthcare seemed to be a persistent undercurrent throughout the course of the debate. The consensus among the candidates was that universal coverage would be less expensive than the current system, despite evidence to the contrary. During the debates, speaking directly to voters, candidates focused attention on high healthcare costs shouldered by the voters themselves. For example, California Senator Kamala Harris highlighted costly high-deductible health plans that sometimes deter people from seeking care.
Guns and Health
The issue of gun control was tied to healthcare policy when Senator Elizabeth Warren referred to firearms-related injuries and deaths as a national health emergency. Other candidates supported the policy of refusing gun licenses to persons diagnosed with mental illnesses. Virtually all of the candidates supported some form of gun control, ranging from ambitious buy-back programs to substantial tightening of licensure and ownership. The basis of the argument maintained that costs related to gun violence increase healthcare costs; for this reason, candidates advocated for gun control as a cost-savings measure.
Even the immigration issue became intertwined with the healthcare debate. On both nights, moderators asked the candidates if they would support extending Medicare coverage to undocumented aliens. All 20 responded that they would. Part of the reason for the unanimity may derive from the current issue of illnesses and deaths among immigrants in detention centers near the border. In the general election, candidates holding this opinion will surely be asked to explain how the promise of free healthcare will not encourage more illegal immigration, thereby making the program more expensive.
Extreme in the Primaries, Moderate in the General Election
To successfully campaign for the White House, a candidate needs to strike a delicate balance between appealing to primary voters, who tend to prefer candidates with more extreme views, and general election voters, who prefer moderation. The practical implication is that candidates with opinions closer to those of Bernie Sanders will have to pivot closer to the center if they hope to win the majority of electoral votes in November 2020.
The danger of endorsing radical proposals during primary season is that the President and his supporters will almost certainly remind voters of these positions during the general election. A possible upside of focusing on healthcare, as well as tying the issue to others during the election season, is that momentum may move toward fixing a system that both sides agree is critically flawed. Another possible outcome is that, as Election Day approaches, these issues will fade to the background and the personalities of the candidates or other areas of interest will take precedence.
The best-case scenario is that a full and frank discussion of healthcare financing will take place on a national scale. First, the extreme rhetoric of primary season will need to turn more moderate. Cooler heads, or at least fewer than 20 heads, will prevail.