The Washington PostDemocracy Dies in Darkness

Voters have big health-care worries, but not the ones Democrats are talking about

Participants hold signs as Sen. Bernie Sanders (I-Vt.) introduces the Medicare for All Act of 2019 on Capitol Hill in April.
Participants hold signs as Sen. Bernie Sanders (I-Vt.) introduces the Medicare for All Act of 2019 on Capitol Hill in April. (Aaron P. Bernstein/Reuters)
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Medicare-for-all. Medicare for all who want it. Health care as a form of freedom. As they campaign, most of the 23 Democratic candidates for president are trumpeting bold ideas to achieve the party’s long-held dream of ushering in health coverage for every American.

The problem is that many voters are not focused on such lofty goals. They want something simpler — to pay less for their own health care.

Voters have plenty to sort out, with nearly two dozen Democrats running, each offering a raft of proposals on many issues. But in public opinion surveys and interviews, people rank health care as their top concern. And with insurance deductibles, prescription drug costs and other medical charges squeezing the middle class, they consistently say they want elected leaders to lower their out-of-pocket costs.

Where 2020 candidates stand on Medicare-for-all and other health-care issues

The disconnect between those views and candidates’ talking points has left voters such as Democrat Ron Jungling of Raleigh, N.C., eager for a nominee who can defeat President Trump — but feeling his party is not speaking to him on a centrally important issue.

“I don’t think it’s probably the right time to push Medicare-for-all,” said Jungling, 57, an electrical engineer whose wife, an insurance broker, has enrolled uninsured clients in Affordable Care Act health plans. His in-laws just went into an assisted-living facility that costs $20,000 a month.

“Medicare-for-all would be great if we could do the other side of the coin — get the cost down,” Jungling said. “I don’t see that happening here.”

Such misalignment — in candidates’ focus and, in some cases, their level of attention — is striking because surveys show that health care is the issue on which the Democratic Party holds the greatest advantage over Republicans. In three polls this year that have asked which party voters trust more to handle health care, Democrats have had an edge over the GOP that averages 19 percentage points.

For his part, Trump, seeking reelection, has repeatedly said he will issue his own health-care plan. For now, he is drawing attention to a series of actions federal agencies can take, including an executive order, expected to be issued Monday, to promote greater transparency in medical costs.

According to pollsters, policy analysts and political strategists, the Democrats’ emphasis on Medicare expansion plans is partly a missed opportunity and partly a reflection of the slice of the electorate that participates in Democratic primaries.

Candidates are failing to recognize that “the debate is not going to be 2008 or ’16 over again. It’s going to be about the price of insulin, hospital charges and insurance premiums, with, ‘What are you going to do about them for me?’ ” said Robert J. Blendon, a Harvard University professor of health policy and political analysis who studies public opinion on health care.

The candidates’ focus on universal coverage, including a plan by Sen. Bernie Sanders (I-Vt.) to eliminate private insurance in favor of a single-payer system, “is a replay of earlier elections [when] it was about getting everybody covered,” Blendon said.

Celinda Lake, a veteran Democratic political strategist, said the candidates could, for instance, capitalize on the fact that public concern about prescription drug prices is a hot issue with both primary and general-election voters. “In my opinion, we’re not talking enough about it,” she said.

Lake said that candidates are playing to the values of Democratic primary voters, who tend to lean further left than others in the party. Unlike the party as a whole, primary voters typically want political leaders to promote access to health care, as well as its affordability.

In a new poll that asked respondents which health-care topics they want candidates to discuss in the first primary debates this week, nearly one-quarter of liberal Democrats said they are most interested in hearing about a single-payer system, compared with just 9 percent of party moderates and Democratic-leaning independents.

Still, lowering the amount that individuals and families pay for health care was the topic of greatest interest to every one of those groups, according to the poll by the Kaiser Family Foundation, a nonpartisan health policy group.

Once a winner emerges from the primary field, the nominee will need to pivot to the theme of affordability, Lake said. The focus, she said, should be on the concerns of insured Americans, given that 98 percent of general-election voters have coverage, while people without coverage are unlikely to vote.

“It is going to be tricky to do,” Blendon said. “It’s going to have to be a shift.

For now, with the exception of Sanders, who has updated a Medicare-for-all bill that was a centerpiece of his first run for president, in 2016, the candidates have not produced detailed health-care proposals.

“We’re at the stage in the campaign where candidates are mostly speaking in bumper stickers,” said Larry Levitt, a Kaiser senior vice president.

That contrasts with the most recent Democratic presidential primary season when there was no incumbent and health care was a dominant issue. Running for the 2008 nomination, then-Sens. Barack Obama, Hillary Clinton and John Edwards each issued a detailed health-care plan by May 2007 — before now in the current election cycle. Ideas from the Obama and Clinton plans became ingredients of the Affordable Care Act, which Obama pushed through a Democratic Congress in 2010 as president.

In 2016, the next presidential election without an incumbent, the GOP wielded the ACA as a club, with Trump vowing to repeal it and Clinton, the Democratic nominee, pledging to improve it.

This year, candidates perceive that at least for now, they have more to lose than gain by laying out specifics, including the price tags of their ideas, analysts said.

Former vice president Joe Biden included in his April campaign kickoff speech a position that is regarded as moderate in this Democratic field. Even for the majority of Americans who get insurance through their jobs, Biden said, “you all should have a choice to be able to buy into a public option plan for Medicare” before 65, the program’s traditional eligibility age.

For the most part, however, Biden is focusing on preserving the coverage expansions and consumer protections created by the ACA. Talking of “total health care” recently, he broached the idea of letting younger people join Medicare, with no insurance premiums, if they would qualify for Medicaid under the ACA but live in a state that has not expanded the program.

Although polls, including by The Washington Post, show voters’ eagerness for political leaders to improve health care, some candidates are giving the issue little attention. On his campaign website, Montana Gov. Steve Bullock (D) includes the phrase “fulfill the promise of universal health care” in the middle of a sentence that sets out eight other policy goals, from breaking the power of Wall Street to tackling climate change.

Sen. Elizabeth Warren (D-Mass.) regales audiences with a thick stream of policy prescriptions that so far do not delve into health care, although she is a co-sponsor of Sanders’s Medicare-for-all legislation.

A few candidates are mingling talk of expanding insurance with empathy about rising consumer costs.

“If you’re uninsured, you’re paying too much for health care,” South Bend, Ind., Mayor Pete Buttigieg says on his website. “If you’re insured, you’re still paying too much.” He heralds guaranteed health coverage as a form of freedom — unleashing people from jobs they keep only because they need the benefits.

In interviews and campaign speeches, Buttigieg says he favors what he terms “Medicare for all who want it,” in which consumers could buy public insurance that, if it proves popular and efficient, could serve as a glide path to a government-run system.

Sen. Kamala D. Harris (D-Calif.) often laces her discussion of Medicare-for-all with memories of her mother dying of cancer a few years ago. During an MSNBC town hall in Spartanburg, S.C., she said she thought at the time about other families burdened with the logistics of care and grief — “and on top of that, [to] have to worry about how they’re going to pay a hospital bill is immoral.”

When Sanders talks of Medicare-for-all, still near the core of his campaign’s rationale, he contends that a single-payer system would be more efficient and would lower the nation’s health-care spending. But reducing overall costs is not a priority with the public, recent polls show.

Although about half of respondents in one poll said they support the basic idea of giving everyone Medicare with little or no role for private insurance, just over 1 in 3 believe it would significantly reduce the nation’s health-care costs. Still other polling suggests people have little understanding of what Medicare-for-all would mean.

Some Democratic voters are drawn to Sanders’s goal.

“We have such wonderful modern medicine, and all these wonderful things are held away from people if they can’t afford it,” said Kisstrin Kaikkonen Cosier, 51, who lives in Marin County, Calif., where she has a small wine business and is a child-care provider and programmer at a local television station. She buys insurance for herself and her 16-year-old daughter through Covered California, the state-run ACA insurance marketplace.

When she caught Sanders on TV the other day, she thought he sounded on the right track. “We ought to have national, free medical insurance,” she said. “Why not? Is our life not important enough?”

Jungling sees it differently. As he listens to the candidates, “I’m hearing more about getting more people covered,” he said. “I think they should do what they need to do to get elected, [but] . . . getting the costs down is the most important thing.”

Chelsea Janes, Sean Sullivan, Matt Viser, Amy B Wang, Cleve Wootson, Emily Guskin and Alice Crites contributed to this report.

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