Sen. Amy Klobuchar (D-MN) answers a question while participating in the Democratic Presidential Debate aon October 15, 2019 (Photo by Win McNamee/Getty Images)

Universal healthcare: It’s been the raison d’etre for Democrats seeking the White House for as long as I can remember.

First, there was candidate and then-President Bill Clinton’s attempt, the much-maligned, stillborn “HillaryCare.” Based in part on the government controlling health care costs, it was rebuked by Congressional Republicans and then voters in 1994, as the GOP seized the House for the first time in a half-century.

Then, as conservatism was on its back at the end of the George W. Bush presidency, there was appetite again for a second try. Horror stories of America’s shambolic system were everywhere in the 2000’s. From Michael Moore’s “Sicko” to songs by Conor Oberst—“Oh, we got no health insurance, no cellular service, no disease, they can cure”—it seemed healthcare, as much as the failing financial system, and the fraught wars abroad, was foremost in everyone’s minds.

In the middle part of the naughties, leading Republicans championed an approach they thought would help preserve the market system—most notably RomneyCare, shepherded in by then-Massachusetts Governor Mitt Romney. Years later, the Right and Romney himself would reject the approach nationally. But the Romney system relied on the individual mandate—that is, requiring citizens to buy private insurance.

The leading Democrats in the 2008 primary—then-Sen. Hillary Clinton, then-Sen. Barack Obama, and 2004 primary runner-up John Edwards—were divided on the matter. Clinton and Edwards favored a mandate, while Obama, often portrayed as furthest left of the trio, actually opposed the mandate. As president, of course, Obama would change his mind and deem it necessary for American healthcare reform.

Heading into 2020, as Democrats nominate a post-Obama, post-Clinton standard-bearer for the first time in years, healthcare still weighs heavily on the minds of both voters and party elites. Obamacare, a relatively moderate, technocratic fix, the thinking goes, cost an ocean of political capital for the Left, only to be dynamited by President Obama’s political successor. Obama didn’t even get a prime attraction of his program through—the public option, that is, a real-deal government rival to private insurance.

If the Left is going to do healthcare reform, the thinking goes, why not go for gold? Republicans will work to sunder any attempt, anyways. As Mayor Pete Buttigieg said this earlier this year: “If we adopt a platform way out to the left, they’re going to say we’re socialists. If we adopt a more moderate or conservative platform, they’re going to say we’re socialists. So, we might as well just do what we think is right, make the case for it and then let them do what they want.”

This dynamic was on full display Tuesday night in Ohio.

The hardcore option is so-called “Medicare for All,” most commonly associated with front-runner Elizabeth Warren and Bernie Sanders, the latter of whom wrote the bill in the Senate, as he reminded us Tuesday night. Warren, whose stock has rocketed in recent weeks, was needled for lack of specificity on how she would pay for the watershed program. Said Sanders: “As someone who wrote the damn bill … I do think it is appropriate to acknowledge that taxes will go up. They will go up significantly for the wealthy and for virtually everybody, the tax increase will be substantially less.”

Warren’s other rivals pulled fewer punches. “I believe the best and boldest idea here is to not trash Obamacare,” said Sen. Amy Klobachur, a consensus breakout star of the debate. “But to do what Barack Obama wanted to do from the beginning and that’s have a public option that would bring down the cost of the premium, and expand the number of people covered, and take on the pharmaceutical companies. That is what we should be doing.” Klobachur added, clearly directing her aim at Warren: “Instead of kicking 149 million people off their insurance.”

The Minnesota senator said the Massachusetts senator’s ambivalence toward repairing Obamacare was evidence that she had bought into “Republican talking points”; Warren said Klobachur’s refusal to embrace a bigger approach also represented bringing a conservative spirit to the problem.

The Warren-Klobachur fracas was emblematic of the fight between the increasingly warring camps on America’s Left: between medicare-for-all and the less ambitious public option, which would offer a Medicare-like plan to folks under 65 and is embraced by Klobachur, the label-ambivalent Buttigieg, and former Vice President Joe Biden. The ex-veep, like Sanders, was quick to remind voters of his relevance to this debate, recalling that he backed the public option hard while in the White House.

Industry is not sleeping on this dynamic, either. Major insurer Kaiser Permanente has released asurvey implicitly favorable to the Biden-Buttigieg-Klobuchar approach, finding only fifty-one percent of people want Medicare-for-all — down from nearly sixty percent last year, before the primary debate kicked out. Kaiser, for its worth, found that 73 percent of people favored a public option. “Biden has cast ‘Medicare for All’ as ‘getting rid of Obamacare’ and Mayor Pete has said you don’t need to gut private health insurance to get to universal coverage,” Washington Examiner senior healthcare reporter Kimberly Leonard told me.

The Democratic Party represents the hopes for millions of disenfranchised and struggling Americans. But its fundamental tensions with its Left is that the party is also composed of much of America’s educated elite, who are generally just fine with their healthcare coverage, thank you very much.

In 2017, Democrats in Virginia and New Jersey rode the healthcare issue to a ballot box bonanza, after the abortive Trump admin healthcare overhaul. Leading Dem strategists hope to repeat that success again. But for a party that hopes to unite before the summer and above all else—replace Donald Trump—the now open rift on a such a seminal issue is worrying.

Curt Mills is senior writer for The American Conservative.