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Medicare for all is divisive, including among Democrats

WASHINGTON — No issue animated the Democrats’ 2018 congressional campaigns like health care and the promises to expand access to insurance and to lower costs. But as House Democrats sit down to draft their vision of governance in the coming weeks, lawmakers find themselves badly divided on the issue that delivered their majority.

Centrists from swing districts, with the tacit support of Speaker Nancy Pelosi, D-Calif., favor incremental moves to shore up the health care law and to lower the out-of-pocket costs of prescription drugs and medical care. They are pushing a variety of measures, such as shutting down cheap, short-term insurance plans that do not cover pre-existing medical conditions and allowing people to buy into Medicare at age 50 or 55.

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“We have very practical solutions that we can implement immediately,” said Representative Kim Schrier, D-Wash., who is also a pediatrician. “We don’t have the luxury of time right now to wait for a full overhaul of our health care system.”

But they are butting up against an aggressive and expanding group of more than 100 outspoken Democrats — as well as at least four of the party’s presidential candidates — who want to do just that, upend the whole system with a single government insurance plan for all Americans — the old concept of single-payer, now called “Medicare for All.”

“I reject the idea that single-payer is impossible,” said Representative Alexandria Ocasio-Cortez, D-N.Y.

The fight will play out in the coming weeks as the new House majority assembles its first budget, a policy document that will not hold the force of law but will carry significant political weight, revealing Democrats’ intentions not only on health care but on taxation, climate change, Social Security and other hot-button issues as well. But more than any other subject, Democrats’ achievements or failures on health care may well define them as they try to defend their fragile majority next year.

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“Health care was on the ballot,” Pelosi declared in November, “and health care won.”

The idea of Medicare for All is immensely controversial. It would greatly expand the federal role in health care. Critics say it would require a big increase in federal spending and proponents have not said how they would pay for it. Some versions of Medicare for All could wipe out much of the health insurance industry and replace employer-sponsored health plans that now cover more than 155 million Americans. Supporters say the proposal would guarantee universal coverage and put health care on a budget, reducing what consumers and employers spend. But many local hospitals and doctors oppose the idea, believing that it would reduce the payments they receive for providing care.

Pelosi cannot afford to put moderate freshmen in Trump-friendly districts on the spot by putting Medicare for All up to a vote.

“Most people receive health care from their employer,” said Representative Scott Peters, D-Calif., a vice chairman for the New Democrat Coalition, a centrist group. “They do not want to replace it with an untested government system.”

But that view is being challenged from some surprising corners of the party. Representative Debbie Dingell, D-Mich., and no one’s idea of an upstart firebrand, is now a champion of the Medicare for All Act. She said the government was already delivering health care to significant areas of the population — the elderly, the poor, service members, children and veterans.

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“We’ve got Medicare, we’ve got Children’s Health Insurance and now it’s time for everybody,” said Dingell, whose husband, John, and his father before him pressed for universal health care when they served in Congress. Before her husband died last month, she said, he told her to “bring it over the finish line.”

The debate reflects how much the political climate around health care has changed since passage of the Affordable Care Act in 2010. President Obama had promoted the idea of a public option — a government-run health program to compete with private insurance on a federally run insurance marketplace — but moderate Democrats balked, and it was not included in the final law.

Senator Bernie Sanders, I-Vt., almost single-handedly put the idea of Medicare for All on the agenda during his 2016 presidential campaign. Since then, the concept has become a kind of litmus test for liberals. Republicans’ dismissal of it as socialism has only emboldened the new wave of liberal freshmen Democrats in the House.

Backers of Medicare for All say that, if framed correctly around saving health care costs, it can appeal to voters in more moderate districts.

“Progressives have done a very good job making the moral case for Medicare for All,” said Representative Ro Khanna, D-Calif. “What we now need to do is make the economic case.”

But with Republicans in charge of the White House and the Senate, the centrists argue that Congress needs to start with more incremental initiatives that could be slipped into larger bills, such as restoring money to enroll people in health plans on the Affordable Care Act’s exchanges. Other bills have bipartisan support; a measure drafted by Senator Susan Collins, R-Maine, would create state-based reinsurance programs to help pay large health insurance claims, thus lowering premiums on the act’s exchanges.

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“After years of damage done to the ACA from past Republican Congresses and the administration, we must start by reversing the sabotage,” leaders of the New Democrat Coalition wrote in a letter to the chairmen of three House committees responsible for health legislation.

Pelosi has publicly stayed out of the fight, but with hearings on Medicare for All and other proposals scheduled in the coming weeks, that stance may not be sustainable. People close to her say she has serious reservations about the single-payer bill and believes the nation can achieve the goal of universal coverage at a more manageable cost by building on the framework of the health care law, which she worked tirelessly to secure in 2010.