Vermont Sen. Bernie Sanders and his call for a government-run health care system are back. On Wednesday, he is laying out a bill that proposes “Medicare for all,” replacing a U.S. health care system dominated by employer-provided insurance — with lots of assorted co-payments and deductibles — to a single-payer approach in which higher taxes fund a system where individuals don’t pay directly for health care. Influential Democratic senators and potential 2020 candidates Cory Booker (New Jersey), Kirsten Gillibrand (New York), Kamala Harris (California), Jeff Merkley (Oregon) and Elizabeth Warren (Massachusetts) have embraced the idea.

“Medicare for all” is going absolutely nowhere anytime soon under a Republican-controlled Congress and President Trump. But here’s the big question: Is it going to become one of the central goals of the Democratic Party and a defining feature of the campaign of whichever Democrat is the party’s nominee in 2020? This seems very likely, at least right now, given the political forces pulling Democrats to the left. But I’m not totally sure, mainly because there are some clear political and policy reasons for Democrats to avoid becoming the party of single-payer.

Why the Democratic nominee may have to strongly embrace Medicare-for-all



1. Some of the party’s most popular figures are already behind it.

FiveThirtyEight’s Nate Silver and Vox’s Matt Yglesias have argued that Sanders is, at least right now, the front-runner for the Democratic nomination for president. If Sanders, who is 76, opts not to run, the 68-year-old Warren seems like an obvious person for Sanders backers to embrace, as she shares many of the same liberal and populist positions. Harris, the daughter of an Indian woman and a Jamaican man, was elected district attorney in San Francisco and has won statewide election three times in California, which is about 40 percent Latino. A candidate with appeal to Asian, black and Latino voters as well as upper-income whites in cities like San Francisco would be formidable in a Democratic primary. I think it’s fair to say that all three of these senators would rank among the top 10 current contenders for the Democratic nomination. Booker is rumored to be considering a run as well. (The online betting site PredictIt ranks these four as among the top five people likely to get the Democratic nomination in 2020, along with former Vice President Joe Biden.)

So Booker, Harris, Sanders and Warren already being for Medicare-for-all greatly increases the chances of the Democratic nominee in 2020 supporting this policy, simply because one of that quartet has a strong chance of being the nominee. And staking out this position, well to the left of where the party was even last November, puts pressure on Biden, New York Gov. Andrew Cuomo and other Democrats who might be considering a 2020 run. Even if one of those candidates privately disagrees with the merits or the strategy of pushing Medicare-for-all, he or she might opt to support the idea to avoid being tagged as insufficiently liberal and therefore out of step with the party’s activist base.

This is how presidential nomination processes often work. In the campaign for the 2008 Democratic nomination, John Edwards came out with a comprehensive health insurance plan, effectively forcing Barack Obama and Hillary Clinton to do the same. (The Edwards plan, with its individual mandate and emphasis on creating health insurance marketplaces, was one of the building blocks of what eventually became the Affordable Care Act.)

This intra-party competition is the biggest and clearest reason to assume Medicare-for-all will become party dogma.

2. The Democrats are becoming a more liberal party.

In 2012, according to the Pew Research Center, about 19 percent of self-described Democrats considered themselves conservative, about 36 percent said they were liberal, and about 41 percent said moderate. Today, a plurality of Democrats (48 percent) describe themselves as liberal. A shift to Medicare-for-all would be in line with this march to the left.

And the party’s elected officials are headed there, too. The new “Better Deal” agenda that congressional Democrats unveiled in July includes a number of Sanders-inspired populist ideas. The party rebranding effort, for example, calls for requiring prescription drug companies to submit an explanation to the U.S. government if they increase the price of a drug by too much.

In this environment, it is much easier to see a centrist Democrat like Cuomo essentially accepting Medicare-for-all as a stance he must take rather than pushing Democratic activists away from Medicare-for-all.

3. The Obamacare experience is moving Democrats.

In 2009 and 2010, when he was stumping for the Affordable Care Act, Obama often highlighted the private marketplaces that would be set up under the law. He mentioned how the ACA would expand Medicaid less often, perhaps with an eye on winning over more independent or conservative-leaning voters who might be leery of more government intervention in the health care system.

But in practice, the private marketplaces have been beset with high rates and insurers fleeing the system, while Medicaid expansion has been popular. This year, as Republicans sought to repeal the ACA, Democrats hammered them on Medicaid, which would have been cut by billions of dollars in the GOP repeal proposals. This defense of Medicaid by Democrats seemed to force even Republican senators like Nevada’s Dean Heller to say they were committed to defending the program.

“One thing has saved the Affordable Care Act from Republicans’ efforts to repeal it: When the votes counted, at least three Republican senators — along with every Democrat in the Senate — could not accept massive cuts to Medicaid,” wrote Mark Schmitt, who runs the Political Reform program at the D.C.-based think tank New America and was a longtime Democratic staffer on Capitol Hill.

Putting more people on government-funded health care programs is an idea that Democrats often favor but sometimes sidestep because they think it is too politically difficult to get adopted. (Obama, in an interview with Vox in January, essentially said that he thought a single-payer system would be more effective, but didn’t think it was possible to get that passed in 2009 or 2010.) The ACA experience has led Democrats — even those who strongly promoted and defended Obamacare — to argue that the ACA has not fixed enough of the country’s health care problems and push for a more comprehensive solution.

Party officials now believe that the public may be open to such a proposal. “It’s always the biggest applause line,” U.S. Rep. John Yarmuth of Kentucky, a Democrat, told me.

Warren, in a blog post on her website, carefully praised the achievement at the center of Obama’s legacy while signaling a desire to move beyond it, writing: “We owe a huge debt to President Obama. Because of the Affordable Care Act, health care coverage is better. … But there’s so much more we could do right now to bring down the costs of quality health care for every American.”

Why the Democratic nominee may be not strongly for Medicare-for-all.



1. A Medicare-for-all candidate may not win the primary.

There was a lot of talk in 2013 about how the Republican presidential nominee three years later would be more liberal on immigration issues than past candidates because of how badly Republicans did in the 2012 election with non-white voters. One of the people pushing that way on immigration (Marco Rubio) also seemed a likely top-tier presidential candidate, the way Booker, Harris, Sanders and Warren are. We know how that turned out.

Some combination of Booker, Harris, Sanders and Warren may not run for president. They might all run and lose. And the candidate who wins the Democratic nomination could be someone who breaks from the Medicare-for-all view, or at least says that he or she is open to other ideas to improve America’s health care system. Maybe that will be a figure like Biden or Colorado Gov. John Hickenlooper, either of whom might run for president and could position themselves as the center-left alternative to the more liberal candidates. In fact …

2. Medicare-for-all is not the only way to expand government-run health insurance.

Liberal wonks, such as Paul Krugman, are not so sure about Medicare-for-all. They argue that such a system is actually extremely complicated to create and that the final product might irritate the millions of Americans who have insurance through their employer and like it.

So some Democrats are proposing ideas like Medicare-for-some (U.S Sen. Chris Murphy of Connecticut) or Medicaid-for-some (U.S. Sen. Brian Schatz of Hawaii). The general idea is that people who are uninsured could buy (or be enrolled for little cost if they don’t make much money) into these programs.

This kind of a policy would be less of a shift to the left. Obama proposed a “public option” in 2009 that would have been similar to the ideas of buying into Medicare or Medicaid that Murphy and Schatz are touting. He dropped the idea after some more conservative Democrats opposed it, but by the end of his presidency, Obama had strongly embraced the idea. Hillary Clinton included a public option in her 2016 platform, though it was not a big feature of her campaign.

Maybe a more moderate Democrat could campaign on expanded Medicaid and Medicare but downplay the “for all” part. And that might have appeal because …

3. Many Democratic voters are not liberal.

I described earlier how liberals are ascendant in the Democratic Party. But according to Pew, the combined group of self-identified moderates (36 percent) and conservatives (15 percent) is as large as the liberals. Whites, people with college degrees, and millennials are disproportionately liberal, while other demographics in the party are not. According to Pew, 55 percent of white Democrats consider themselves liberal, compared with 28 percent of black Democrats and 41 percent of Latinos. About 60 percent of Democrats with postgraduate degrees consider themselves liberals, compared with about 37 percent of Democrats with a high school degree or less.

You could imagine New Orleans Mayor Mitch Landrieu pitching himself as the candidate who can appeal to working-class whites and more moderate Democrats. And part of that pitch could be running on a health care plan that is more likely to be passed into law than Medicare-for-all.

In June, Pew polled Americans on creating a “single-payer” health care system. Only 33 percent of the public overall supported the idea, although 52 percent of Democrats backed it. I assume Democratic support for Medicare-for-all will grow with more leading figures in the party embracing it. Also, the poll asked people about a single national health insurance system run by the government, not “Medicare-for-all,” which I suspect is a much more popular notion. But the survey did not ask respondents about “Medicare-for-all” versus “Medicare-for-some,” which might also be a popular idea. So public opinion on this issue could well shift in a number of directions.

I’m inclined to think that whoever receives the Democratic nomination in 2020 will support Medicare-for-all, either because he or she truly believes in the idea or because party politics effectively force this. I’m not so sure that this idea will ever become U.S. policy — or even come to a vote in Congress. But its embrace by Booker, Harris and Warren less than a year after the election tells us two important things about American politics right now: Sanders lost the Democratic Party’s nomination, but he may have emerged as the party’s intellectual leader. And the Democrats appear to have concluded from 2016 that, at least on economic issues, they should move left, not right.