A decade ago, Democrats in Congress were deep into the process of designing and debating the health care law that would become Obamacare. Tea Party protests were about to spring up around the country in opposition to the law. And President Barack Obama was on the verge of delivering a major address defending the law from its critics, and hoping to rally support from his own party.
In that speech, Obama positioned his approach as a middle ground between two extremes. "There are those on the left," he said, "who believe that the only way to fix the system is through a single-payer system like Canada's, where we would severely restrict the private insurance market and have the government provide coverage for everyone. On the right, there are those who argue that we should end the employer-based system and leave individuals to buy health insurance on their own."
The following year, Obamacare became the law of the land, and the signature initiative of Obama's two-term presidency. But in last night's Democratic primary debate, which featured a full half-hour segment focused on health care—which was introduced as "the number-one issue for Democratic voters"—it was virtually absent. Instead, the evening's leading contenders extensively defended Medicare for All, a single-payer plan that captured elements of both the extremes Obama said he wanted to avoid.
Medicare for All, as proposed by Sen. Bernie Sanders (I–Vt.) and vigorously supported by Sen. Elizabeth Warren (D–Mass.), would end the nation's employer-based health care system and, in the space of four years, replace it with a fully government-run system that is closest to Canada's, but even more restrictive, leaving virtually no room for private insurance. It would, according to both independent estimates and Sanders himself, raise government spending on health care by something like $30 or $40 trillion over the next decade. And it would require tax hikes or tax-like fees or premiums on the middle class. In terms of both cost and transition complexity, it would dwarf Obamacare.
Sanders and Warren spent much of the debate's opening segment defending these ideas from tough questioning by the moderators and criticism from more moderate candidates who argued that the plan was too radical, too unpopular, and too unworkable. The polls, at least, suggest that there is some truth to this: Medicare for All is popular in the abstract, but quickly becomes unpopular when respondents are told that it would eliminate private health insurance or raise taxes.
Arguably the strongest criticisms came from John Delaney, a Maryland Democrat who in the early 1990s founded a health care financing company. Delaney warned that the radicalism espoused by Warren and Sanders would turn off more moderate voters in an election. "We don't have to go around and be the party of subtraction, and telling half the country, who has private health insurance, that their health insurance is illegal," he said. "My dad, the union electrician, loved the health care he got from the IBEW. He would never want someone to take that away. Half of Medicare beneficiaries now have Medicare Advantage, which is private insurance, or supplemental plans. It's also bad policy. It'll underfund the industry, many hospitals will close."
This was a point that Delaney had made before: the Sanders plan, as expensive as it already is, calls for paying Medicare rates for all services, which would mean a substantial reduction in rates for doctors and hospitals. He repeated it later in the evening. "I've been going around rural America," he said, "and I ask rural hospital administrators one question, 'If all your bills were paid at the Medicare rate last year, what would happen?' And they all look at me and say, 'We would close.'"
Warren and Sanders had essentially no response to this. Warren accused moderates on the stage of spinelessness, and both she and Sanders argued that questions and criticisms about single-payer health care amounted to "Republican talking points." They took shots at drug makers, which represent about 10 percent of total U.S. health care spending, and insurance companies, which on average have profit margins of less than 3 percent, for profiting off of health care, but never addressed questions about payment rates for providers.
Nor would Warren respond directly to a question about whether she would raise taxes on the middle class to fund the plan. Sanders has admitted that it would require higher taxes, and Warren has said she's with him on his ideas. But when asked by moderator Jake Tapper whether she's "'with Bernie' on Medicare for all when it comes to raising taxes on middle-class Americans to pay for it?" she prevaricated. "So giant corporations and billionaires are going to pay more," she said. "Middle-class families are going to pay less out of pocket for their health care." And then she went on to attack insurance companies, repeating the same basic formulation about "total costs" going down when Tapper pressed her again on taxes. Warren clearly didn't want to answer the question.
Following the debate, CNN's Anderson Cooper pressed her on the question of upheaval: What would she say to people to liked their current health plans? How did she respond to the idea that Obamacare was already a tough sell politically, and Medicare for All would therefore be even more difficult? Once again, Warren deflected, accusing critics of timidity and spinelessness.
Looked at one way, Medicare for All had a rough night, facing difficult questions and a phalanx of criticism from the stage's more moderate contenders. But the critics who fought with Warren and Sanders last night have essentially zero support in the party. Delaney, for example, currently polls at 0.7 percent. And while better-polling contenders like Kamala Harris and Pete Buttigieg have plans that call for something less than full-fledged single-payer, they are speaking something like the language of Warren and Sanders.
The only Democratic candidate who has strongly attacked Medicare for All who has performed well so far is former Vice President Joe Biden, who will appear in the debate's second round tonight. But even Biden's plan has been framed largely as a response to Medicare for All, a way of pushing back against its excesses.
Somehow, in the space of 10 years, Democrats have drifted away from Obama's performative centrism, his (at least rhetorical) sense that what Americans want is a middle way, an anti-radical solution rather than the "big structural change" that Warren insists is needed. Medicare for All, and all the troublesome questions it raises, is defining the 2020 Democratic race—and the Democratic Party with it.