Democrats in swing districts are increasingly worried that the outspoken embrace of Medicare-for-all by Bernie Sanders and other top Democratic presidential hopefuls could hurt their chances of keeping the House in 2020.

The tension is evident across the country, from suburbs where voters fear higher taxes, more government and the demise of private insurance, to campaign rallies in Iowa and New Hampshire, where some candidates are cheering Medicare-for-all as a moral imperative.

The health-care dispute is part of a larger question Democrats face in the lead-up to the 2020 election: Do they want to run on a platform that takes an ax to laws governing health care, immigration, the environment and financial regulation, or is it better to use a chisel?

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The strains came sharply into focus on a recent afternoon in Washington, when Sanders, a senator from Vermont, delivered a speech promoting Medicare-for-all as the only way to fix problems with the current system and the best path to “guarantee health care for all Americans as a right.” He warned, “Now is not the time for tinkering around the edges.”

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That pitch does not sit well with many Democratic House members, especially those in centrist districts who helped deliver the House majority to Democrats in 2018.

“I think it’s a losing message for 2020, and I think the Democratic presidential candidates have to realize that this is not a far-left country nor is it a far-right country,” said Rep. Anthony Brindisi (D-N.Y.), speaking in the Capitol that afternoon. “I think we’re all very vulnerable the further to the left some of the presidential candidates go.”

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Brindisi, who unseated a Republican in a central New York battleground district last November, is the kind of freshman Democrat whose fate is likely to determine whether the party retains its majority in the House.

Rep. Kim Schrier (D-Wash.) is another. “I think it is a mistake to want to blow up the system that is working pretty darn well the way it is,” said Schrier, a pediatrician with Type 1 diabetes who won a Republican-held seat in the suburbs and exurbs of Seattle last year.

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Schrier said she supports a public health-insurance program, which would let people take part in a government system if they want, rather than requiring them to do so.

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Sanders’s enthusiasm for Medicare-for-all is hardly unique among the Democratic candidates. Sens. Elizabeth Warren (D-Mass.) and Kamala D. Harris (D-Calif.), among others, have joined him in endorsing the idea, responding to an energized Democratic base that’s pushing for a sweeping liberal agenda to counter President Trump’s policies.

That surge from the left puts Brindisi, Schrier and other Democratic centrists in a tough spot. The more than 40 Democrats who took House seats from Republicans in 2018 are by definition from swing districts, and their voters generally favor a more cautious approach.

Many of those freshmen are hoping to duplicate in 2020 their successful midterm strategy of castigating Republican attempts to repeal the Affordable Care Act and touting their efforts to preserve the law and its popular protections for people with preexisting medical conditions.

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But the political battle lines are no longer so clear. More than half the Democratic presidential field favors some form of Medicare-for-all, which would mean transitioning away from the ACA, an Obama-era health-care law that others in the party would rather retain and improve. Among the top-polling candidates, only former vice president Joe Biden advocates that more modest approach.

Trump and other Republicans are seizing on the push for Medicare-for-all to warn about the uncertainty that would engulf any new system, and some Democrats are openly fretting that this message will resonate.

“I can think of few other issues that have more of a down-ballot effect than Medicare-for-all,” said former congressman Steve Israel (D-N.Y.), who chaired the House Democrats’ campaign operation in 2012 and 2014. “In a context where Donald Trump is going to turn every idea into a socialist plot, talking about building on the Affordable Care Act is the high ground. Trying to defend Medicare-for-all becomes problematic.”

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But that’s not how many of the presidential candidates see it. The most ardent defender of Medicare-for-all is Sanders, who’s been leading the charge for years. When he challenged Hillary Clinton for the Democratic nomination in 2016, his plan had yet to gain a foothold in the party. Three years later, it’s much more mainstream.

The broader embrace of Medicare-for-all is politically complicated for Sanders. It puts the debate firmly on turf he’s long found comfortable, but he has lost his status as the only candidate championing a sweeping overhaul of the health-care system.

Harris and Warren, for example, have signed on to Sanders’s health-care bill in the Senate. “I’m with Bernie on Medicare-for-all,” Warren said at the first Democratic debate. “I spent a big chunk of my life studying why families go broke, and one of the number-one reasons is the cost of health care, medical bills.”

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When politicians say it can’t be done, she added, “what they’re really telling you is they just won’t fight for it.”

Sanders’s plan would make the government the insurer for everyone in the United States, guaranteeing universal coverage. Private insurance companies would be barred from duplicating benefits offered under Medicare-for-all, which would effectively limit them to optional and supplemental procedures, Sanders has said.

Warren raised her hand in the first Democratic debate when the candidates were asked whether they wanted to abolish private insurance in favor of a government-run plan. The Republican National Committee, seeing an opportunity, posted the exchange online with the headline, “Warren proudly raises hand in support of kicking millions off private health insurance.”

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Warren and other supporters of Medicare-for-all say private insurance would be replaced by coverage that’s cheaper, better and fairer. But Brindisi said people in his district want to fix the ACA and stop the GOP’s attacks on the law, not reinvent the American health-care system.

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“For any presidential candidate to raise their hand and say that they want to be for eliminating private health insurance, that is a losing message in 2020, and I would encourage them to rethink their positions,” he said.

Sanders, estimating that his plan would cost 30 trillion to 40 trillion dollars over 10 years, acknowledges it would require a tax hike on middle-class Americans — another point that could be hard for Democrats in centrist districts to swallow. Sanders argues that Americans would come out ahead by not having to pay private insurance premiums.

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The main alternative in the party is extending the reach of the ACA with a public option, the centerpiece of Biden’s health-care plan. In recent weeks, he has campaigned heavily on his proposal and warned that a transition to Medicare-for-all could pose coverage risks for people who depend on the ACA.

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“I have no doubt about the intention and the fervor and sincerity of Bernie and Elizabeth and Kamala,” Biden told reporters in Las Vegas on Saturday. “But it’s a long, long way home.”

The debate is likely to sharpen next week when Democrats debate for the second time. Harris and Biden will again appear on the same stage, opening the possibility of a more direct conflict on health care.

Some Democratic strategists are starting to worry that the party won’t present a unified health-care message in 2020. It may depend, they say, on who the presidential nominee is, adding that some House Democrats may have to distance themselves from the top of the ticket if it’s Warren or Sanders.

Finding a balance between exciting voters and reassuring them can be tricky, as evidenced by Harris’s recent comments on health care.

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Harris seemed to suggest in the first debate that she supports abolishing private insurance, then clarified that she does not. And while she has said she opposes a middle-class tax hike to fund Medicare-for-all, she has yet to fully explain how she would pay for it.

That has not been lost on Biden. “You have a lot of people out there supporting [Sanders’s] plan and are running and saying, ‘But I’m not for that tax,’” Biden said in Las Vegas. Then he added in a stage whisper, as though revealing a big secret: “There’s no way to pay for it.”

Advocates of Medicare-for-all argue that it is not only possible to support the idea and win in centrist districts, but that it could even attract additional voters there. Rep. Katie Hill (D-Calif.) defeated a Republican in a suburban Los Angeles district last year, running as a proponent of Medicare-for-all, which is also known as a single-payer system.

“What people are most concerned about is not the term ‘Medicare-for-all,’ ” said Hill, who has endorsed Harris in the presidential race. “They care more about how you are going to help them right now and what government is doing for them, what our values are.”

Rep. Alexandria Ocasio-Cortez (D-N.Y.), who supports Medicare-for-all, argued that many voters dislike their private insurers and would not object to reducing their role.

“I was at a town hall and I said, ‘Who here loves their Blue Cross Blue Shield insurance?’ And not a single person raised their hand,” she told reporters recently. “People like their health care, they like their doctor, but I’d be interested in what the public polling on Aetna would look like.”

But some of her colleagues hope someone who is not in favor of ending private insurance will emerge from the crowded Democratic presidential primary.

“There’s a lot of presidential candidates who have different ideas, but one of them has not been picked to be the nominee yet,” said Rep. Elaine Luria (D-Va.), who flipped a Republican-held seat in 2018. “I think that’s still up for debate, and I will certainly be looking for a candidate who has a more reasonable proposal than that.”