WASHINGTON — A list of supporters of Senator Bernie Sanders’s new government-run health plan reads like a who’s who of the Democratic Party, including Senator Kamala Harris of California, Senator Kirsten Gillibrand of New York, Senator Cory Booker of New Jersey, and Senator Elizabeth Warren of Massachusetts.
But while support for so-called single-payer insurance has grown significantly since Sanders made the issue a bedrock of his 2016 presidential campaign, the glitzy names of top-level supporters — many of whom are prospective Democratic candidates for president in 2020 — mask a real divide among rank-and-file Democrats nationwide. As the 2018 midterm elections loom, and Democrats aim to reestablish control of Congress by winning tough seats in conservative-leaning districts, many are questioning whether a gargantuan government takeover of the health care system, and the required higher taxes to pay for it, is the right policy for an already wounded Democratic Party.
Sanders’s plan could cost more than $32 trillion over a decade, according to a nonpartisan analysis of the Vermont senator’s similar presidential campaign proposal.
“Have people already forgotten that Obamacare barely passed? And is hanging on by a thread?” said Larry Sabato, the director of University of Virginia’s Center for Politics. “For the time being, meaning the next few elections, Democrats need to win some blue-wall Democrats back, and I don’t think the way to do it is to talk about increasing taxes.”
Sanders, an independent from Vermont, unveiled the broad strokes of his plan Wednesday, along with 15 Democratic cosponsors. Still, only one Democrat out of the 15 hails from a state that President Trump won in November, and few come from the once-Democratic Rust Belt states so critical to Trump’s rise. Prominent Democratic leaders including House minority leader Nancy Pelosi, Senate minority leader Chuck Schumer, and party chair Tom Perez have declined to support single-payer insurance; and Democratic governors across the country have been reluctant to embrace the prospect of government-run health care, even in such progressive places as California.
“Reforms are just beginning to bear fruit,” said a statement by Governor John Hickenlooper of Colorado, who opposed a 2016 single-payer ballot initiative in his state. “It would be premature to dramatically remake our health care system at this time.”
Some Democrats fear Sanders’s single-payer movement could risk hurting the party’s electoral prospects in the short term, if it becomes a liberal litmus test nationwide and crowds out candidates where a moderate Democrat would have a better chance of success.
Sanders’s supporters, notorious for their passionate advocacy and crisp organization for liberal causes, have often disrupted the Democratic order by exerting significant pressure on legislators who haven’t backed their desired causes.
Katherine Clark, the Massachusetts representative who has a senior role in Democratic efforts to take back the House of Representatives in 2018, said she hopes single-payer does not become a litmus test for liberal candidates running for office.
Clark is a cosponsor of the House version of Sanders’s single-payer bill, and Massachusetts Democrat Ed Markey also signed on as a cosponsor for the Senate version.
But Clark does not feel explicit support should be a necessary ingredient for Democrats running nationwide.
“I think that having good, robust debate about where we take health care in this country is going to be a good one for Democrats,” Clark said. “What we’re seeing is candidates coming forward with a range of solutions that match the communities they’re hoping to serve.”
Democrats have been divided on this issue since at least the 1970s, and the debate loomed large over Senator Edward M. Kennedy’s primary challenge of President Carter in 1980. Kennedy lost, but he continued stoking the dream of a government-run, guaranteed health insurance plan for all Americans for the remainder of his life.
Passage of the Affordable Care Act — a hybrid plan that relies on government subsidies and private insurance coverage — put the single-payer debate on hold for seven years, as Democrats reveled in their victory. But now, liberal Democrats are feeling emboldened by Republicans’ failure, thus far, to make good on their promise to repeal the landmark health law.
In interviews, several Republican strategists said they were glad Sanders and other high-level Democrats have embraced single-payer. Republicans feel the program is easy to demonize as socialist and expensive, and the Republican National Committee is already using the Democratic disagreements on single-payer to needle vulnerable Democrats in 2018.
“Democrats have moved so far left that they have to be even more liberal than Nancy Pelosi to appeal to progressives,” said Michael Ahrens, a spokesman with the Republican National Committee, previewing the coming attacks. “Those eyeing a 2020 campaign know the base will only support candidates who embrace ultra-liberal policies like single-payer, which is guaranteed to raise taxes on the middle class.”
Evan Siegfried, a Republican political strategist, said Democrats are “snatching defeat from the jaws of victory” by prioritizing single-payer and not just focusing on moderate fixes to the ACA.
For Democratic senators in tough reelection campaigns in the midterm elections, such as Missouri Senator Claire McCaskill, Indiana Senator Joe Donnelly, and West Virginia Senator Joe Manchin, the ACA is an easier prospect to defend than single-payer insurance, Siegfried said.
“They’re putting 2020 before 2018,” Siegfried said.
Sanders himself concedes there is a low likelihood of his bill becoming law in the near future, but single-payer advocates believe they are on the right side.
Morally, they say, health care is a human right, and the wave of recent activism stoked by Republican attempts to repeal the ACA has only intensified that belief. Politically, backers say the bill is a chance for Democrats to step past their rhetoric of resistance and rally around a positive vision for the country’s direction independent of Trump.
They also disagree with the notion that the measure is unpopular or would hamstring supporters in midterm elections. For evidence, supporters often point to Sanders’s strong primary showing in the Rust Belt states of Michigan and Wisconsin, plus recent polling from the Kaiser Family Foundation that showed 53 percent of Americans now favor single-payer, the highest recorded total in decades.
“We are spending almost 18 percent of our GDP on health care,” Sanders said at a rally in Washington announcing his “Medicare for All” bill Wednesday. “Health care for all is not only a moral issue, but an economic issue.”
American support for a government-run program is partially true, said Drew Altman, president of the Kaiser Family Foundation and an expert on health care polling. As a general rule, health care policies often enjoy support when they are abstract ideals, but that can easily crater once the ideal becomes a legislative possibility.
Exhibit A, according to Altman, is the Republican attempts to replace the ACA — which enjoyed widespread backing until it became a Capitol Hill reality.
“With sweeping health policy plans, they’re kind of like hurricanes that lose steam over land,” Altman said. “Opinion is malleable and will change once you get to real debate.”
Single-payer “is a concept that energizes the Democratic base, just as repealing the ACA was a concept that energized the Republican base,” said Dan Mendelson, a former health official in the Bill Clinton administration and current chief executive of Avalere Health in Washington.
“It is also analogous because it’s not politically feasible in the short or medium term,” Mendelson said. “It would be associated with significant legislative inertia if it was ever seriously attempted.”
Still, experts said, this should take nothing away from Sanders’s accomplishments. Just two years ago, Sanders could not find a single cosponsor for his single-payer bill. Last year, Democratic presidential nominee Hillary Clinton was adamantly opposed to the idea.
“People who have health emergencies can’t wait for us to have a theoretical debate about some better idea that will never, ever come to pass,” Clinton said.
Less than 18 months later, more than one-quarter of all Democratic senators were lining up in support.
Clinton, having failed to win the White House, is on a book tour.