Democratic voters’ focus on health care keeps that issue at center stage in the presidential primary, with the spotlight shining most brightly on the politics of “Medicare for All” — the 2020 shorthand for universal government-provided health insurance.

National polling almost universally shows that Democrats rank health care as one of the most important election issues (as U.S. House Speaker Nancy Pelosi recently reminded anyone who would listen), and that they overwhelmingly favor of providing the universal coverage promised by Medicare for everyone.

Yet public opinion polling in Texas reveals significant disagreement about the details of delivery, particularly whether government-provided health insurance should entirely replace existing private insurance, including plans provided in full or in part by employers.

A closer look at the health care preferences of Democratic voters illustrates how the potential embrace of Medicare for All has critical implications for the general election — and not entirely to the Democrats’ advantage. Results from the February 2020 University of Texas/Texas Tribune Poll illustrate how the phrase “Medicare for All” masks a problem for Texas Democrats in both the primary and the general election if health care remains at center stage in 2020.

At first cut, the focus on health care makes as much sense in Texas as it does nationally. Among Texas Democrats, health care was second to only one issue on the list of the most important problems facing the country, behind the “political corruption and leadership” they attach to the Trump presidency. Health care is similarly ranked among Democrats’ views of problems facing the state.

In order to gauge the fundamental question about health care policy, the UT/TT poll asked a variation of a question frequently used in national polling:

"Which would you prefer: the current health insurance system in the United States, in which most people get their health insurance from private employers, but some people have no insurance, OR a universal health insurance program, in which everyone is covered under a program like Medicare that's run by the government and financed by taxpayers?"

Given that choice, Texas Democrats overwhelmingly prefer universal health care. Seventy percent of Democrats said that they prefer a universal program. (Eighteen percent preferred the current system; 12% said that they didn’t know). This is a large majority, though not overwhelming. By comparison, 91% of Democrats support background checks for all gun purchases, 79% say government should do “a great deal” or “a lot” about climate change, 77% say income inequality in the U.S. is a major problem, and 82% disapprove strongly of Donald Trump’s job performance. So 70% is high, but there are things Democrats agree on more.

More critical for Democratic prospects in 2020 is the resistance to abolishing private insurance that lurks behind that support for universal health care. When the 70% who favor a government-run system were asked, "Would you favor or oppose a universal health insurance system if it eliminated all private health insurance?", 76% would continue to favor the universal system, 14% would oppose it, and 10% were unsure. These small shares add up. A few calculations point to significant misgivings about making government the sole provider for health care. If you combine the 30% who don’t clearly favor universal coverage with the universal health care supporters who blanch at abolishing private care, nearly 47% of Texas Democrats have reservations. That’s faint praise for what could be the marquee proposal for the Democratic presidential campaign.

This problem for the Democrats is not confined to the presidential election. This thorny problem has trickled down into the quiet Democratic Senate primary. In a recent debate, 11 of the 12 candidates were asked to simply weigh in — “yes” or “no” — on the proposal to expand Medicare to all Americans. Rightfully or not, that’s a quick litmus test for who occupies the left lane versus the left-of-center lane. Per Abby Livingston’s coverage in The Texas Tribune, four answered yes (Michael Cooper, Annie “Mamá” Garcia, Sema Hernandez and Cristina Tzintzún Ramirez) and seven no (Chris Bell, Amanda Edwards, Jack Daniel Foster Jr., Victor Hugo Harris, MJ Hegar, Adrian Ocegueda and Royce West).

In purely political terms, presidential frontrunner Bernie Sanders’ dedication to Medicare for All capitalizes on an issue that is highly salient to Democrats, but that becomes a potential wedge issue for Republicans up and down the ballot in the coming general election. The reticence of most Texas Democratic Senate hopefuls to embrace Medicare for All (including consistent polling leader Hegar) reflects these strong cross-currents among Democratic voters, as does the persistence of those presidential candidates who are less committed, in either scope or pace of implementation, to a transition to a government-run, single-payer government system.

It’s nearly an article of faith among Democrats that health care provides them with a winning campaign issue, as reflected in Pelosi’s recent comments that the party’s message in 2020 should be “health care, health care, health care.” If the 2020 campaign were shaping up to be a reasoned policy debate, Republican candidates’ ability to inflame divisions among Democratic voters would have significant limits. The Trump administration’s intermittent attention to health care has mostly come in the form of attempts to use executive authority and the courts to undo major provisions of Obamacare, while speaking in support of its most popular and effective provisions.

Texas still has the highest rate of uninsured residents in the 50 states — 17.7% in 2018, according to the U.S. census. Health care is, on its face, not a good policy debate for Republicans, particularly in Texas, where, after almost two decades in control, the GOP has sole ownership of the state’s shortcomings on this front.

Of course, presidential elections rarely coincide with reasoned policy debate, and an election with Trump as a candidate makes such a tone exponentially less likely, either nationally or in Texas. Should Sanders’ growing success lead to his nomination as the Democratic presidential candidate, the flogging of his democratic socialist pedigree by Republicans will include dark tribal rhetoric on health care meant to redirect any discussion of the failures of incumbents, in the national campaign and in the dozens of potentially competitive races in Texas, toward painting all Democratic candidates as part of resurgent red threat to the American and Texan way of life.

Texas Democrats’ unity in their intense desire to be rid of Trump poses the biggest electoral threat to Republican hegemony in Texas in at least a decade. Against that, denouncing Medicare for All in any form as the harbinger of socialism provides an ideal way for Republican candidates to change the subject without renouncing the president and earning his ire — while at the same time playing on evident doubts among Democratic voters. Republican attacks on Democratic health care proposals have already begun, and they take place in an inflamed election environment that is more polarized and angrier than any time since the Civil War, and noisier than ever thanks to the media environment.

The lack of Democratic consensus on the solution will be further weaponized by Republicans from Trump on down. Even if Sanders falters or is otherwise denied the Democratic nomination, Democratic candidates should expect any attempts to mobilize their partisans on the health care issue to trigger Republican alarms about socialism or worse. Once the primary contests now in full bloom are behind them, Democrats’ success will depend on their ability to close ranks in the name of defeating Trump and leave the final settlement of specifics of the health care solution for some time in 2021.

Disclosure: The University of Texas at Austin has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.