George Belken was in his Des Moines home on a recent Sunday afternoon when he heard someone at the front door. He yelled, "Whoa!" when he saw Pete Buttigieg on the other side of the screen door.

The Democratic presidential candidate was soon making a personal pitch to Belken and his wife, Jan, on his "public option" health care plan. The proposal, he said, would let Americans determine whether to keep their private insurance or jump to government-run coverage.

The Belkens, both 68 and retired, said Buttigieg's plan made sense. The couple is skeptical of "Medicare for All," the single-payer health care proposal supported by U.S. Sens. Bernie Sanders of Vermont and Elizabeth Warren of Massachusetts.

"Not everybody will want to do that," Jan Belken predicted. "They have a right to choose."

The Belkens are still undecided about for whom to caucus in February, but they agreed to put a "Pete" yard sign out front.

The South Bend, Indiana, mayor is betting other Iowans are also scrutinizing Medicare for All, the policy idea that's dominated the health care conversation this election cycle. He's used television appearances and ads in recent weeks to proclaim that Medicare for All will take away choice for Americans.

"Iowans, by nature, are practical," Buttigieg told the Des Moines Register. "I think this is a state where people are strong in progressive values, and also looking for a way to deliver on those values that's not polarizing."

His approach may be working. A Suffolk University/USA TODAY Poll released after the Oct. 15 Democratic primary debate, where Buttigieg drew his sharpest distinction on the topic yet, showed Buttigieg behind only former Vice President Joe Biden and Warren among likely Democratic caucusgoers in Iowa.

It's also opened up the mayor to criticism that he's inconsistent in his views and his messaging, especially as he goes after Warren on health care. Buttigieg makes no apologies about his policy, which he calls "Medicare for All Who Want It."

"If there's a real distinction between me and my competitors on the issue that's top of mind, I gotta make sure everybody understands it," Buttigieg told the Register.

'My lane is for everybody else'

A Des Moines Register/CNN/Mediacom Iowa Poll, conducted in September by Selzer & Co., showed some reservations about Medicare for All in the first-in-the-nation caucus state. Forty-one percent of likely Democratic caucusgoers support the policy — defined in the poll as "shifting to a completely government-run health system" — and think candidates should advocate for it.

Another 28% in the poll were personally comfortable with the policy but feared it could cost the party the general election. Twenty-four percent said it’s bad policy, and 8% weren't sure. The poll of 602 likely Democratic caucusgoers was conducted Sept. 14-18, and the margin of error is plus or minus 4 percentage points.

Buttigieg is trying to carve a lane for himself over those Medicare for All doubts.

He is one of the most prolific fundraisers in the race — he raised $19.1 million in the third quarter of the year and has $23.4 million cash-on-hand to spend. But he trailed Warren, Biden and Sanders in the Iowa Poll released in September.

Buttigieg alludes to the trio when asked about the state of the race.

"If you want the left-most possible candidate, you've got your choice and it isn't me. And if you want the most established and Washington-tenured candidate possible, you've got your choice. And again, it isn't me," he said. "I guess my lane is for everybody else."

Kevin Cavallin is trying to figure out where he belongs on that political spectrum. At a Buttigieg town hall in Ames this month, the 48-year-old openly pondered his interest in the mayor, Biden and Warren.

Cavallin described Biden as a "safe option" and Warren as a "progressive option."

"I'm seeing Buttigieg as a hybrid between the two," Cavallin said. "His policies are more progressive and moving the Democratic Party in the right way, but yet not so progressive that I'm afraid they're going to scare away the moderates and the independents."

An early message gains new attention

Buttigieg, 37, has talked about his support for a public option — which he describes as making Medicare available to younger people through a market exchange — since the earliest days of his presidential campaign.

"The flavor that I prefer is what I would call, "Medicare for All Who Want It," Buttigieg said in a PBS NewsHour interview that aired on Feb. 15, days after his first visit to Iowa as a presidential hopeful.

The phrase "Medicare for All Who Want It" soon became a staple of Buttigieg's campaign stump speech, and he released a policy plan about it last month. But the topic gained the most attention on Sept. 12 during the Democratic primary debate in Houston.

"The problem, Sen. Sanders, with the damn bill that you wrote, and that Sen. Warren backs, is that it doesn't trust the American people.I trust you to choose what makes the most sense for you, not my way or the highway," Buttigieg said to applause during the televised event.

Buttigieg's campaign quickly promoted the exchange on social media and cut television and digital ads on the theme of "choice" in health care.

Pauline Lloyd saw Buttigieg give a speech days later at a former storefront in Iowa Falls. The 63-year-old drove in from Union, a nearby community of fewer than 500 people.

"People are scared of that, especially in our area," Lloyd said of Medicare for All and the potential cost. "We're not going to be able to afford that."

At the next Democratic primary debate on Oct. 15, Buttigieg singled out Warren for not answering whether her Medicare plan would increase taxes on middle-class families.

"Your signature is to have a plan for everything, except this," Buttigieg told Warren.

Buttigieg isn't the only one pitching an alternative to Medicare for All. Vice President Joe Biden has talked about improving the Obama-era Affordable Care Act. U.S. Sen. Kamala Harris of California wants a government-run health care system that keeps private insurance. Other Democratic 2020 candidates, including U.S. Sen. Amy Klobuchar of Minnesota, back some variation of a public option.

Klobuchar also criticized Warren on health care during the last debate.

“The difference between a plan and a pipe dream is something that you can actually get done,” Klobuchar said to Warren. “And we can get this public option done.”

Buttigieg and Klobuchar later announced their campaigns had each raised more than $1 million in the first 24 hours after the debate.

Risk for Buttigieg

Buttigieg's efforts to differentiate himself on health care come with risk.

Some political commentators accused the mayor of being disingenuous with his criticism of Warren. They point out that Warren, like Sanders, wants to get rid of co-pays and other out-of-pocket costs, lowering the overall expenses of health care for Americans in the long run.

Buttigieg has described Warren's Medicare plan has having a "multi-trillion-dollar hole" when it comes to cost.

"It's an honest and very important policy disagreement," Buttigieg told the Register. "They think that it's OK to force people off their private plans. And I think that's a mistake. So, I don't know how it isn't fair to talk about it."

Warren claimed during the Oct. 15 debate that Buttigieg's health plan would exclude low-income people, which the Buttigieg campaign denies. After the same debate, Warren announced in Iowa that she soon would share how she would pay for her plan in a way that did not hurt middle-class Americans.

Buttigieg estimates his public option plan would cost about $1.5 trillion over a decade and would be paid for in large part by repealing the corporate tax rate in a tax overhaul bill pushed by President Donald Trump.

People on social media also noted that Buttigieg tweeted his support for the concept of Medicare for All last year.

Buttigieg addressed the tweet on the "The Tonight Show Starring Jimmy Fallon" on Monday.

"Yeah, for the long run, that's still my preference," he said. "I just think we got to have some humility about this. In other words, to get from here to there, it makes more sense to make it optional."

Buttigieg's policy attack against Sanders and Warren could also belie his effort to portray himself as a candidate above the political fray. Buttigieg doesn't see it that way.

"I don't think anyone expects us to paper over our differences, or pretend we're not competing," Buttigieg told the Register. "I do think that we're expected to do it in a way that's factual. That's respectful. That's decent. So part of what I'm setting out to do, even or perhaps especially when we're getting really competitive, is to show that we can hash out these differences without being unkind. And that's the other side of the coin, of making sure no one confuses kindness for weakness on my part."

Barbara Rodriguez covers health care and politics for the Register. She can be reached by email at bcrodriguez@registermedia.com or by phone at 515-284-8011. Follow her on Twitter @bcrodriguez.

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