Democratic voters want single payer health care. But don’t expect to hear Democratic candidates talk about it — at least not in those words.

To avoid divisive intraparty fights that drive candidates left — only to be attacked by Republicans for favoring socialized medicine — the Democratic Congressional Campaign Committee warned aspirants last year about the political liabilities of endorsing “single payer,” according to sources familiar with the advice. An influential progressive group even urged candidates to discard the often-misunderstood phrase and embrace “Medicare for all” to draw strong connections with the popular seniors’ health program.


A third of the way through the 2018 primaries, Democrats have largely prevented the Bernie Sanders-led groundswell of single payer support from swamping the contests. And they're fine tuning their messaging to build support for the idea. Kara Eastman, a progressive Democrat hoping to knock out incumbent Republican Don Bacon in Nebraska’s second congressional district, pledged to support the idea but refuses to use the term “single payer,” calling it a “buzzword.”

It’s an important distinction in the handful of races where single payer advocates have made it onto the ballot. Those include many of the GOP-controlled House districts in California that Hillary Clinton won in 2016, and the Senate contest pitting Democrat Sen. Dianne Feinstein against fellow Democrat, Kevin de León, who’s emphasizing health care and civil liberties. It has also made the ballot in more unexpected places, such as Nebraska.

Those contests will decide whether the idea is strong enough to drive turnout from the progressive base, or whether it repels the independent or GOP voters needed to win.

“I certainly have been worried that our party was going to have an internal debate between people who favor single payer and people who didn’t favor single payer,” Sen. Chris Murphy (D-Conn.) said recently when he rolled out legislation with Sen. Jeff Merkley (D-Ore.) to allow all Americans to buy into new Medicare plans, regardless of age.

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Expanding health coverage in that kind of way is a largely philosophical discussion as long as President Donald Trump is in the White House. But it is one that Democrats will have to confront before the wide-open 2020 presidential primaries, where ambitious ideas like single payer could be a litmus test, and the general election, where the parties are likely to play up their widening divide on health care.

“It’s important to have a number of different, aggressive proposals out there so that they’ll be subject to debate in 2018 and 2020,” Murphy said.

Some Democrats argue that instead of focusing on the potentially divisive idea of single payer, the party should defend the Affordable Care Act against "sabotage" from Trump and congressional Republicans, who combined to repeal the individual mandate and scrap a key subsidy program that helps cover low-income people. That message is more compelling this year, argues Brad Woodhouse, campaign director of pro-Obamacare group Protect Our Care.

“We’re out of power right now, we can’t make any of that happen,” he said of single payer health care. The vast majority “of what you do when you’re out of power is prosecute the case against what they’ve done — otherwise there is no reason to make a change.”

While Democrats grapple over what kind of health care expansion they support and what to call it, Republicans are poised to brand any support for a public option or expansion of Medicare as a vote for single payer and liken it to Britain's government-run health system.

Going into this year’s primary season, Democrats worried single payer talk would fuel public feuds between candidates such as California gubernatorial hopeful Gavin Newsom, who came in first in the state’s primary, and Antonio Villariagosa, who advocated against Medicare for all and finished third. They also worried progressives' support for the idea would force moderates to do likewise in swing districts where the issue is more vulnerable to GOP attacks.

Democrats took several steps to neutralize the threats.

Early last year, the DCCC shared verbal guidance with candidates and political consultants about the liabilities of supporting single payer, including polls that showed support for the idea declined once voters heard that it would likely come with significant tax increases and the potential loss of private health coverage many Americans have today, according to sources who saw the guidance.

Democrats also wrote a number of bills to expand access to health care. In addition to the Murphy-Merkley bill, Democrats proposed allowing people to buy into Medicare, buy into the Medicaid program and add a government-run health option to private payer options. The multiple options provided needed cover for candidates who backed expanding access to government health programs but didn't feel comfortable embracing Sanders’ plan.

And when the GOP tried to divide Senate Democrats by forcing a vote on a single payer health care bill last July, progressive Democrats banded together to vote “present,” avoiding a visible rift for Republicans to exploit. Red-state Democrats up for reelection this cycle, including Montana's Jon Tester and Heidi Heitkamp of North Dakota, voted against single payer to firm up their moderate bona fides.

Meanwhile, the Progressive Change Campaign Committee, one of the biggest political organizations promoting a single payer health system, began urging candidates to avoid the term and use “Medicare for all.”

“There is no more popular brand in America or the American government than Medicare — or Social Security. Democrats should be wrapping themselves in the flag of Medicare,” said PCCC co-founder Adam Green.

Single payer has a mixed record on the ballot this year.

Eastman waged an upset campaign in an Omaha-area primary by running on Medicare for all. But Democrat Laura Moser lost a Texas congressional primary doing the same. So did Pete D'Alessandro in Iowa, despite backing from Sanders.

All seven of the GOP-controlled California districts that Clinton carried in 2016 are likely to have a Democratic candidate that supports Medicare for all or more cautiously, a candidate who supports a “path to” Medicare for all. (Not all of the primaries have been called.) The idea of government-run health care is particularly popular in California, a state that tried to implement its own single payer plan and typically leads the country on progressive policy.

For that reason, Eastman’s race in Nebraska could be the most revealing test of whether single payer is a viable route for Democrats in 2020.

Critics worry that the Omaha-area district could be one of the places where progressive policies could be a liability against a Republican incumbent.

“National progressives who up until recently couldn’t find Omaha on a map have now turned her into a cause, and they’re going to be able to test the theory that an unabashed progressive can win a Republican-leaning swing seat,” quipped one Democratic political consultant.

Eastman’s camp rebuffs that idea, arguing that Medicare for all — a policy that she supported in part because of the sky-high drug bills her mother got during an illness — is one of the reasons she prevailed in her primary against former Democratic Rep. Brad Ashford.

Still, Eastman has gone to great lengths to explain her support for Medicare for all, even writing in a blog post that she refuses to use the term “single payer” because it is a poorly understood buzzword. Her campaign acknowledged that Medicare for all policy is in relative infancy and that detailed explanation is important.

“There is an education piece at play here,” said campaign spokeswoman Heather Aliano. “We have to be careful to take the time to explain what we’re talking about.”

Support for single payer has jumped exponentially in a short period of time.

About 59 percent of Americans favor a government-run national health plan, according to a March poll by the nonpartisan Kaiser Family Foundation. Support for the idea increases to three-quarters when framed as a national Medicare-for-all plan option to compete alongside private plans.

Similarly, a late 2017 Gallup poll found 47 percent of people support a “government-run” program instead of a system based mostly on private health insurance. That’s up from 34 percent just four years ago. Both polls found the idea far more popular with Democrats.

Republicans say there is little distinction between single payer or Medicare for all. The National Republican Congressional Committee promises to make it an issue in general election contests.

“It’s become the litmus test issue for Democrats in their primaries,” said spokesman Jesse Hunt. “So it’s going to be the forefront of the conversation.”

CORRECTION: A previous version of this story misspelled the name of Heather Aliano.