Hear that crunching sound?
It's the eggshells that 2020 Democratic presidential hopefuls are stomping through, backing up and stomping upon all over again, as they attempt to satisfy the base's delicate demands for Medicare-for-all.
The left-wing die-hards sometimes argue that supporting Medicare-for-all should be a litmus test for anyone seeking the 2020 nomination because it’s not only good policy but good politics, too. The entrenched establishment may claim it’s a “radical” idea, but surveys suggest it is mainstream.
"If I look at polling and 70 percent of the people support Medicare for All, if a very significant percentage of people think the rich, the very rich, should start paying their fair share of taxes," Sen. Bernie Sanders, I-Vt., told The New York Times, "I think I'd be pretty dumb not to develop policies that capture what the American people want."
In a sense, Sanders is right: The phrase "Medicare-for-all" polls favorably (though not always at 70 percent), and has for several years.
Here's the problem. The things Americans are apparently envisioning when they tell pollsters they support Medicare-for-all turn out to be a different, vaguer and more varied set of ideas than the specific thing that Sanders, Rep. Alexandria Ocasio-Cortez, D-N.Y., and others in the progressive base are proposing.
Sanders, et al. want all Americans enrolled in a single, generous, government-run -- or single-payer -- plan with no private insurers offering their own similar, competing policies. Sanders said he envisions the role of private insurers only for "cosmetic surgery, you want to get your nose fixed." (To be clear, this is not how Medicare currently works; the program relies heavily on privately run insurance plans.)
How does the public feel about this?
If you simply ask, "Do you favor or oppose having a national health plan, sometimes called Medicare-for-all?," 56 percent of respondents favor it, according to a January Kaiser Family Foundation poll.
But mention that Medicare-for-all involves getting rid of private insurance companies, and support plummets to 37 percent. Which should not be that surprising. Most adults have private insurance, and most of them like it. They're nervous about losing it.
Sen. Kamala D. Harris, D-Calif., learned this the hard way, when the presidential candidate spelled out during a CNN town hall last week that she favored eliminating private insurance.
After a backlash, Harris’s staff walked back her comments, noting that she preferred Sanders-style single-payer but had also co-sponsored other bills that allowed existing private insurance plans to coexist alongside expanded public insurance. That, in turn, inflamed the left. A former Sanders staffer said it was equivalent to saying “you’re OK with people dying for being too poor.”
Wary of provoking the single-payer-or-bust-ers, other Democratic 2020 candidates have given incoherent or noncommittal remarks on the subject. Pete Buttigieg, the mayor of South Bend, Ind., said he supported “single-payer” but also the use of private insurers, eventually endorsing “Medicare for all who want it.” Sen. Cory Booker (N.J.) confusingly said he supported the continued existence of “private health care,” which might mean insurers but also might simply mean providers.
Sens. Elizabeth Warren (Mass.) and Kirsten Gillibrand (N.Y.) -- who, like Harris and Booker, co-sponsored Sanders' single-payer bill -- have both sidestepped the issue. Asked about private insurance, Warren said last week there were a lot of paths to get to "affordable health care for every American."
And you know what? That's the right answer right now.
The thing Americans want most, if you look at the polling, is not single-payer per se. They want universal, affordable coverage that doesn't leave them begging on GoFundMe for their kids' insulin. In that same Kaiser survey, support for "Medicare for All" was highest -- 71 percent -- when respondents were told it would "guarantee health insurance as a right for all Americans."
And purity tests aside, there are many ways to achieve that outcome. Across health policy wonkland, there are vibrant debates over many alternative ideas. These include allowing non-elderly adults to buy into Medicare; allowing employers to purchase Medicare for workers; a Medicaid buy-in program; and enrolling all newborns in a government health plan.
Rather than insisting that "there's no viable path to the Democratic nomination for someone who does not support single-payer health care," as one progressive writer put it, Democrats should start with principles and objectives, and figure out the most effective and feasible route to them.
This is the richest country on Earth. Truly, we can figure this out. But not if we let the perfect become the enemy of the good.
Catherine Rampell
Catherine Rampell’s email address is crampell@washpost.com. Follow her on Twitter, @crampell.