In the aftermath of the midterm elections, many commentators have marveled at the apparent groundswell of public support for single-payer health care under the slogan “Medicare for All.” In a recent Health Affairs Blog post, our colleagues identify this “explosion of support” as evidence of the political viability of a single-payer platform and call on congressional leaders to advance single-payer legislation.

We wholeheartedly support any policies that would make our deeply flawed health care system more equitable and efficient. However, polling data do not reveal sufficient public support for Medicare for All to justify the claim that it is “now within the realm of political possibility.” Investing hard-earned political capital in a single-payer health plan without a popular mandate is a risky political strategy. Rather than attempt to justify massive tax increases and cancellation of millions of private insurance plans to a polarized US public, the new US House Democratic leadership should instead put forth a progressive agenda that targets the known causes of health disparities through poverty alleviation, housing assistance, and criminal justice reform, among other policies to advance health equity.

Defining “Medicare For All”

Claims of broad support for Medicare for All are largely overstated. A great deal of media coverage was devoted to one recent poll in particular, in which 70 percent of respondents (including 52 percent of Republicans) either strongly or somewhat supported providing Medicare to every American. Polls such as these tend to find support for the phrase “Medicare for All,” which crumbles when explained or clarified. For example, the Henry J. Kaiser Family Foundation (KFF) found that 62 percent of Americans support Medicare for all, yet only 48 percent prefer the synonymous “single-payer health insurance system.” When respondents were told that it would require increased taxes, only 34 percent still favored Medicare for all. This finding was replicated in a recent Politico/Harvard T.H. Chan School of Public Health poll.

To some extent, these findings may be explained by public confusion regarding the meaning of Medicare for All. Politicians have helped create this confusion by using the phrase indiscriminately to leverage Medicare’s powerful brand and to build support for universal coverage. “Medicare for All” most commonly means replacement of the United States’ mess of public and private payers with a single-payer system, as defined by Sen. Bernie Sanders, House Medicare for All Caucus co-founder Pramila Jayapal, and the popular bills their colleagues have co-sponsored. However, some have used the term to express support for a universal Medicare buy-in option (also known as a public option), while others believe it means a lowering of Medicare’s age of eligibility or even buy-in for Medicaid. To equate support for Medicare for all with support for a tax-financed, government-run national health plan is misleading given the substantial proportion of voters who don’t understand the policy behind the phrase.

Brittle, Polarized Support For “Medicare For All”

Furthermore, the support that does exist falls along deep partisan divides. The Politico/Chan analysis found that while 70 percent of likely Democratic voters supported a single-payer system, only 21 percent of Republicans did. A little more than a third of independents showed support in a separate KFF poll. Additionally, a November Gallup poll revealed that nine out of every 10 Republicans oppose a government-run health system, and only 27 percent of them believe that the government should ensure that all Americans have health care coverage. And although Democrats and independents most frequently named health care as their top issue before the midterms, Republicans ranked it eighth in importance, on par with the budget deficit and foreign policy. Interestingly, independents’ attitudes on a single-payer system were closer to those of Democrats rather than Republicans; in the KFF poll, 58 percent were “strongly” or “somewhat” in favor.

The partisan divide among the electorate helps explain the split within the Democratic Party. While several prominent newly elected Democrats campaigned supporting Medicare for all, almost none (3 percent) of the Democrats who upset incumbent Republicans in competitive districts did. H.R. 676, the House’s single-payer bill, does indeed have the support of more than half of House Democrats, but the current bill is largely symbolic. By signing on as a co-sponsor, officials score points with the Party’s progressive base yet bear no political risk. The names absent from the bill’s list of co-sponsors are far more revealing: incoming Speaker of the House Nancy Pelosi, House Majority Leader Steny Hoyer, and Energy and Commerce Committee Chairperson Frank Pallone.

Lessons From Vermont

Even when voters and their elected representatives support a single-payer system, politicians may balk when faced with the political consequences of tax increases and cancellation of private insurance policies. Vermont passed a single-payer law in 2011, but after running the numbers, the state abandoned its plans. A massive tax hike and the cancellation of hundreds of thousands of private health insurance plans proved too much for Vermont Governor Peter Shumlin and his party to endure.

At the national scale, left-leaning Vermont’s challenges would be even tougher for the more conservative US body politic to face. Senator Sanders’ single-payer plan would increase federal spending by approximately $32 trillion over the next decade, but as written, would raise only half that amount of revenue through a slew of fees that fall primarily on the wealthiest taxpayers. To achieve budget-neutrality, any successful single-payer scheme would probably need to ask more of US households than the paltry 2.2 percent income tax and 6.2 percent payroll tax currently in the bill. Moreover, a real single-payer law would cancel more than 175 million private insurance policies, yet the Affordable Care Act was nearly felled by the infamous promise “if you like your plan, you can keep it” to around two and a half million Americans. Most Americans really like their insurance, and about half of them mistakenly believe that they could keep it under a single-payer system.

By their nature, single-payer plans can engender significant political backlash. This underscores the importance of building the broad, bipartisan public consensus necessary to give political cover to politicians that might otherwise lose their seat over a vote for a single-payer plan. Without a public mandate for change, the political barriers to Medicare for all loom large.

Now Is The Time To Address Social Determinants Of Health

Pursuit of Medicare for all without sufficient public support risks wasting valuable political capital that could be used to advance social policies that would improve health. Only about 20 percent of variation in health outcomes can be explained by differences in health care. The US spends approximately the same proportion of gross domestic product on the combination of health care and social services as most other developed nations, yet we spend far more on health care and far less to promote the social determinants of health. This disparity has likely contributed more to our nation’s poor health outcomes than variations in access to health care. Pushing for an increased minimum wage, better access to treatment for substance use disorders, criminal justice reform, and increased access to affordable housing would all serve as more achievable political goals, while at the same time bringing us closer to a more just and equitable system.

Addressing the social determinants of health and pushing for universal health care coverage are not mutually exclusive paths of action. For single-payer advocates, now is the time to answer difficult questions about what Medicare for All means and to strengthen and expand the foundations of the Medicare for All movement by cultivating public support. For now, our elected leaders should invest their newfound political capital judiciously on policies that are more likely to advance health equity.