The health care long game: Biden, Harris, and Medicare for All

Former Vice President Joe Biden’s selection of Sen. Kamala Harris as his running mate has meant different things to differently situated liberals and progressives. But as regards health care, the message is clear. 

Harris’s presidential run failed in large part because she couldn’t stake out a coherent place in a crowded field of health care proposals. Sen. Bernie Sanders had already occupied the left flank with his thoroughgoing support of ushering in a “single payer” or “Medicare for All” system, so there was little political utility in Harris moving there, even if she had wanted to. Sen. Elizabeth Warren struggled to find a clear position ever-so-slightly to Sanders’ right, and got wrapped up in explaining whether she would get rid of private insurers altogether. 

Meanwhile, Biden, former Mayor Pete Buttigieg, Sen. Amy Klobuchar, and a few others clustered in the middle, offering a range of proposals promising to build on the Affordable Care Act and preserve the Obama legacy, while gesturing to bigger plans in the future. Buttigieg’s comically titled “Medicare for All Who Want It” illustrates the rhetorical gymnastics in which these candidates found themselves entangled. Harris’s plan contained many good ideas, it just didn’t fit easily into either of the ideological poles. Health care, as we’ve been told “is complicated.” The politics of health care is often even more so.

In the end, Biden triumphed on the promise that he is the standard bearer to President Barack Obama’s legacy, and that legacy is strongly grounded in health care reform. The strong support of Rep. James Clyburn in South Carolina was a pivotal moment in Biden’s campaign, especially as concerned his ability to win large majorities of the African American vote in the South. But, more than anything, what pushed Biden over the line was a growing sense within the electorate, whether right or wrong, that playing it safe would ensure victory. More than any one policy, it turns out, most Democrats want Donald Trump gone.

But what would a Biden-Harris administration mean for health care reform? While Biden must remain loyal to the Obama legacy, which means building on the Affordable Care instead of scrapping it and starting again, Harris has more room to maneuver. Over the next four years, if they can win in November, it is likely not only that they will take steps that will nudge the country toward something like Medicare for All, but it is just as likely that necessity will push them there. In the short term, Biden and Harris are able to have it both ways, issuing assurances to those who are averse to sweeping and abrupt change while keeping larger aspirations fully intact.

Harris’s plan envisioned a slow, ten-year climb to a Medicare for All program that would guarantee all Americans access to essential health care services, with a $200 cap on out of pocket costs. The details of this defunct plan don’t matter much now. The more important point is that Harris supports the basic idea of Medicare for All, understands the idea’s importance within progressive politics, and she seems open to tinkering within the broader policy framework. That’s a good starting point, particularly at this political moment.

Many Medicare for All supporters are befuddled by the fact that so many Americans continue to defend a health care system that does not serve them well and endangers the lives of millions of Americans, with particularly egregious disparities experienced by Black and Brown, disabled, and poor Americans. Many can’t grasp why support for Medicare for All has not skyrocketed during the COVID-19 pandemic, which laid bare the indignities and shortcomings of virtually every facet of the U.S. health care system. If not now, during a pandemic that has left our national economy and health care system in tatters, then when?

Yet, unpopular though it may be to say from a progressive perspective, public opinion confirms the wisdom of pursuing public alternatives to private insurance, at least in the short term, before going all in on Medicare for All. While it’s true that Medicare for All has gained steam — the Kaiser Family Foundation’s tracking poll now consistently reports that a majority of Democrats support the idea, at least in principle — the story is also more complicated than that. Kaiser, after all, also finds that “more Democrats and Democratic-leaning independents would prefer voting for a candidate who wants to build on the ACA in order to expand coverage and reduce costs rather than replace the ACA with a national Medicare-for-all plan,” a view that tends to center on an expanded role for public programs such as Medicaid and Medicare. 

Beyond the present electoral moment, it is important to remember that coveting the finished product of an attractive policy idea is different than grasping what the implementation of that idea looks like. Unintended consequences, and the backlash they can cause, are critical to consider. All too often, Medicare for All advocates fail to take seriously the legislative majorities that would not only be required to pass such legislation — and we are far from such a position — but the need to defend those legislative majorities as Medicare for All is relentlessly attacked, legislatively as well as in the courts, just as the ACA was.

As Kaiser’s Drew Altman wrote back in February, “Republican voters have moved on from hating the ACA,” and “have shifted their sights to Medicare-for-all,” signaling a shift from the venom directed at the ACA to Medicare for All. (Speaking of courts, there is one caveat to all of this, as it is possible that, even if Biden gets elected, the Supreme Court could overturn some or even all of the Affordable Care Act in the first half of 2021. If that happens, all hell could break loose and Medicare for All could see new life.)

As Medicare for All advocates note, there could be some political risk in not supporting Medicare for All in this election. Some disenchanted Sanders supporters will inevitably stay home in November. But these political risks are overstated. Biden and Harris understand that there is still more electoral downside to going all in on Medicare for All, and the Biden-Harris approach is likely to bring along the lion’s share of Sanders and Warren supporters while also pulling from the political center and even the center right, such as the demographic to which the Lincoln Project is appealing.

Biden and Harris don’t expect progressives to love this idea. But they are betting that progressives will come to accept it. Whether the Biden-Harris approach to health care grows into bigger, system-transforming policy vision will depend on the continued mobilization of progressives, who have already taken the idea from a pipe dream to a possibility.

In declaring himself a transitional future president, Biden is attempting to set the table for eight, twelve, or possibly more years of Democratic leadership. But if we seek not only a course correction to Trumpism, which amounts to a full-on assault of not only progressive, but even softer, basic liberal values, like democracy and the basic rule of law, then this election must set a stage for a long recovery. Long recoveries require strong foundations and broad coalitions. Most importantly, they require winning elections. All indications are that Biden and Harris understand this.