In summer 2009, while Democrats in Congress were deep into the process of designing the health care reform that would become the Affordable Care Act (ACA), Tea Party protests sprung up around the country in opposition to the law. In a primetime speech delivered that September, President Barack Obama hoped to convince critics on the right and in his own party that Obamacare was 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 this year's Democratic primary contest, it has few defenders. Health care policy has dominated the early debates, consuming more discussion time than virtually any other issue. But many top-tier candidates have made the case for Medicare for All, a single-payer plan that captures elements of the extremes Obama said he wanted to avoid.
Medicare for All, as proposed by Sen. Bernie Sanders (I–Vt.) and supported by Sens. Elizabeth Warren (D–Mass.) and Cory Booker (D–N.J.), would end the nation's employer-based health care system. In the space of four years, it would implement a fully government-run system that is similar to Canada's but even more restrictive, leaving virtually no room for private insurance. Sanders' plan, according to both independent estimates and Sanders himself, would raise government spending on health care by $30–$40 trillion over a decade. It would also require tax hikes or tax-like fees on the middle class. In terms of both cost and transition complexity, it would dwarf Obamacare.
The plan is not without its critics in the primary. During the initial Democratic debates, former Maryland Rep. John Delaney argued that paying Medicare rates for all services, which the Sanders plan calls for, would cause hospitals to close, since the amounts are typically much lower than those offered by private coverage. Delaney also argued that the plan would cause union members to lose their current coverage, an idea echoed by former Vice President Joe Biden, whose own proposal calls for expanding Obamacare's subsidies and adding a government-run health insurance plan that people could opt into. Prominent Senate Democrats, meanwhile, have suggested they would pursue expansions of Obamacare and Medicare rather than a full-fledged single-payer system, suggesting the strongest form of the idea faces long legislative odds.
Yet even Democrats who have not backed a single-payer system have appropriated the language of Medicare for All. Pete Buttigieg, the mayor of South Bend, Indiana, has touted a plan he describes as "Medicare for All Who Want It," which calls for an opt-in expansion of the program as it exists today. And after multiple flip-flops on the question of whether she would allow private health insurance, Sen. Kamala Harris (D–Calif.) proposed permitting private insurers to offer heavily regulated plans through the infrastructure of Medicare. Her proposal would eliminate employer-sponsored insurance as we know it, the political drawback she was presumably attempting to avoid. Like Sanders, she also calls her plan Medicare for All.
What all of these plans share is a rejection of the status quo. They are premised on the understanding that Obamacare does not work in its current form and that another significant overhaul is necessary. Even Biden's plan, which he has framed as a defense of the ACA, amounts to a tacit admission that the law has not achieved its goals.
The Democrats who are embracing the single-payer vision of Medicare for All, meanwhile, have dispensed with Obama's notion of a middle way between left and right, of an approach that preserves popular elements of the modern American health care system.
There is, perhaps, some virtue to such blue-sky thinking, insofar as it represents a useful break from the status quo bias that has long defined the health policy debate for the worse. But it also demonstrates an unmistakable and newly prominent streak of radicalism on the political left. Medicare for All is not only the defining issue of the 2020 Democratic primary race; it is the issue that is defining the entire Democratic Party.