In the fall of 2017, with more than three years to go before the next presidential election, Sen. Bernie Sanders (I-VT) introduced Medicare for All legislation in the Senate. The bill racked up a long list of high-profile co-sponsors, many of whom were already being talked about as 2020 contenders.

Since then, Sens. Elizabeth Warren (D-MA), Kamala Harris (D-CA), and Kirsten Gillibrand (D-NY) — all co-sponsors of Sanders bill — have jumped into the Democratic fray. So, too, have former Housing and Urban Development Secretary Julian Castro, Rep. Tulsi Gabbard (D-HI), and South Bend, Indiana Mayor Pete Buttigieg, among a few other lesser-known candidates.

Along with their senatorial rivals, Castro, Gabbard, and Buttigieg have all expressed support — or at least an openness to — single-payer health care as well. Sanders himself is reportedly preparing to announce his own candidacy in the coming days.

It’s a field that would have been unrecognizable in 2016, when former Secretary of State Hillary Clinton, the face and onetime future of the Democratic Party, railed against Sanders’ proposed single-payer system during a debate.


“I do think when you make proposals and you’re running for president, you should be held accountable for whether or not the numbers add up and whether or not the plans are actually going to work. If someone promises you something for free, read the fine print,” Clinton said in April 2016.

Interestingly, a study from the conservative think tank Mercatus found last July that Medicare for All would save the United State trillions, and 70 percent of all Americans — including 85 percent of Democrats and 52 percent of Republicans — support Medicare for all, according to a Reuters poll from last August. Just 20 percent of Americans said they oppose the idea outright.

“Even candidates with very focused campaigns that run based on focus groups, that are more calculating than ‘This is my ideology,’ they have decided that they have to run in a calculated way on Medicare for All,” Ben Day, the executive director of Health Care Now, a single-payer advocacy group, said in an interview with ThinkProgress.

But, he cautioned, advocates are going to keep a close eye on politicians who have gotten on board simply because they feel they have to. “Those folks have a different relationship to the issue than the folks who have gotten on because they believe it in their hearts and it’s part of their moral fiber,” Day said. “There are forces trying to keep the for-profit middle men in the [single-payer] system that you switch to.”

Single-payer activists across the country, in conversations with ThinkProgress, echoed Day. As the Democratic primary gets underway, advocates want clear answers from contenders about what they really mean when they talk about Medicare for All and confirmation that their vision for single-payer in the United States includes the complete elimination of private health insurance, coverage for all residents including undocumented immigrants, reproductive health coverage, and, in some areas, goes beyond Sanders’ Senate bill.


“There’s going to be a lot of attempts to politically compromise the system,” Day said. “But almost all those changes make the system more expensive, and you create opposition to the system within the system.”

In other words: If a Democratic presidential contender offers you Medicare for All, read the fine print.

Many advocates pointed to simple human rights principles — universality, equity, transparency, accountability, and participation — for assessing health care proposals. Optional Medicaid buy-ins, for example, mean coverage is determined by your wallet and immigration status. Getting health care through your job can be similarly dicey.

In the coming weeks, Rep. Pramila Jayapal (D-WA) plans to introduce Medicare for All legislation in the House, a bill that advocates told ThinkProgress they expect will address some more specific concerns they’ve had about Sanders’ single-payer vision, including long-term care coverage.

In Sanders’ bill, long-term care, which is vital for seniors and many with disabilities, is left in the hands of state Medicaid programs, which are mandated only to maintain their “current level” of spending. Activist Tim Faust told ThinkProgress that’s simply not enough.


“By keeping long-term-care standards and payment at the state level, Sanders’s bill offers no protections against the worst abuses of state-funded long-term-care,” Faust said in an email. Those abuses include liens being placed on the homes of people who need long-term care, people with disabilities being forced out of their homes and into nursing homes, and couples being forced to get divorced in order to allow one partner to qualify for Medicaid.

Additionally, advocates want to hear a clear plan from primary contenders for the elimination of private insurance for-profit health care institutions.

“We…feel strongly that [for-profit institutions] would need to be bought out so that they would continue to operate as health care institutions but in a not-for-profit way,” Carol Paris, the immediate past president of Physicians for a National Health Program, said in a recent interview. “If we don’t buy them out but somehow or another tell them, ‘Well you’re not allowed to make a profit off of Medicare and all the care is Medicare,’ they’re going to end up selling [or] they’re going to convert their hospital into a hotel or a convention center, and then we’re not going to have enough hospital beds.”

But more than anything, Paris said, before getting to the details, she wants to hear from candidates that they have a clear understanding that Medicare for All means exactly that: Coverage for all medically necessary care and no barriers to that care at the point of service. No co-pays, no deductibles, no need for supplemental policies, no private insurance.

“I want to know that candidates are using that term to mean improving traditional Medicare and expanding it to everyone from birth to death residing in the United States,” she said.

At a town hall Monday night, CNN’s Jake Tapper asked Harris whether, under her vision of Medicare for All, people are going to lose the insurance they have right now.

Calling for Medicare for All, Kamala Harris says of private insurance: ”Let’s eliminate all of that. Let’s move on.” pic.twitter.com/xT2I5IZDfT — Shane Goldmacher (@ShaneGoldmacher) January 29, 2019

“The idea is that everybody gets access to medical care. You don’t have to go through the process of going through an insurance company, having them give you approval, going through the paperwork, all of the delay that may require,” Harris said. “Who of us has not had that situation, where you’ve got to wait for approval and the doctor says, ‘Well, I’m not sure whether your insurance company is going to cover this.’ Let’s eliminate all of that. Let’s move on.”

That sort of clear, straightforward answer about how single-payer would look in the United States is exciting for advocates. But their worst fears were realized Tuesday evening, after a day of furor from Republicans and centrists, when CNN reported that an advisor to Harris had told the network Harris would be open to other health care plans, including plans that would compromise with private insurance.

In a statement to CNN, Ian Sams, a spokesperson for Harris said, “Medicare-for-all is the plan that she believes will solve the problem and get all Americans covered. Period. She has co-sponsored other pieces of legislation that she sees as a path to getting us there, but this is the plan she is running on.”

Responses like this are precisely why advocates worry 2020 contenders will emphatically push for single payer in their messaging — but will come up short or reverse course when probed for details.

“I’m encouraged but I’m still not persuaded that any of these candidates is going to be the thing that makes Medicare for All happen,” Paris said. “That is going to require a continued popular movement.”