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April 13, 2020

Will the 2020 Election Resolve the Question of Medicare for All?

Author Affiliations
  • 1Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 2John F. Kennedy School of Government, Harvard University, Cambridge, Massachusetts
JAMA Health Forum. 2020;1(4):e200339. doi:10.1001/jamahealthforum.2020.0339

Political news coverage might lead one to believe that the 2020 election will settle the question of whether the country will move toward Medicare for All. This is, however, unlikely to be the case.

Obstacles Facing Enactment

First, Medicare for All legislation is unlikely to be enacted in the follow-up to the 2020 election. Such an outcome would require the election of a Democratic president committed to Medicare for All, as well as a Democratic majority in the US House of Representatives and 60 or more Democratic senators, all of whom would have to be committed to supporting the legislation. Also, as of today, large numbers of Democrats in the House and Senate have not chosen to sign on to a Medicare for All bill. This is important because, given the political polarization in Congress, it is unlikely that any Republicans will vote for Medicare for All legislation. When the Patient Protection and Affordable Care Act (ACA) was passed in 2010, it did not receive a single Republican vote, in contrast to the 1965 enactment of Medicare, when nearly half the Republican members of Congress voted in favor.

The Current Divided Situation

However, difficulty in passing Medicare for All legislation in the aftermath of the 2020 election does not mean that the issue will disappear from the health care agenda. Not widely recognized is that a majority of people in the US are telling pollsters that they favor multiple different approaches to changing the health care system: enacting Medicare for All (52%-56%)1,2 and keeping the ACA (55%), including having a public option (66%)1 and allowing adults younger than 65 years the option to buy health insurance through Medicare (72%).3

When asked what their first choice would be among 3 possible changes in the nation’s health insurance system (Medicare for All, improving the existing ACA, and replacing the ACA with state-based health plans), Americans are almost evenly divided in their preferences. None of the plans emerges as the most-preferred option of a majority of the public. However, Medicare for All is the option most favored by a majority of liberal Democrats (52%).4

The Changing Politics of America

This is important because polls show that a growing proportion of Democrats are identifying as politically liberal, and liberal Democrats are younger on average than moderate or conservative Democrats.5 Liberal Democrats are more likely than moderate or conservative Democrats to support Medicare for All (52% vs 39%) most among the 3 options tested against each other.4 Fundamental changes that are moving the Democratic Party in a more liberal direction are likely over time to increase the number of voters committed to Medicare for All.

The Future of the Debate

As a result, if Democrats do not have the votes in Congress or the president elected in 2020 does not favor Medicare for All, it is likely to remain an issue in Democratic primaries and general elections for years into the future. In addition, it will persist because younger adults aged 18-29 years are more likely than those 50 years or older to support Medicare for All (63% vs 53%).2

It is important to recognize how perspectives can change over time. In 2010, Americans’ views about a public option were divided (49% to 51% in favor in 3 polls),6 and a public option was not included in the ACA because of concerns it would affect overall support that legislation. Now, 10 years later, when people are polled about a public option or a Medicare buy-in, public support is 66% and 72%, respectively.1,3 So it is not impossible that, regardless of the 2020 election, support for Medicare for All could increase over time.

This might particularly be the case if a Medicare buy-in was enacted by a future Democratic administration and Congress and a large number of Americans chose the Medicare option. After a decade of experience with the ACA, a large majority of the public favors having the opportunity to buy into Medicare. If Americans decide to enroll in Medicare in large numbers and it turns out to be less expensive for businesses, individuals, and families, this could lead to a second wave of discussion about moving to a single, stand-alone Medicare program that includes coverage for people younger than 65 years. Like Medicare today, it could still offer the choice of a private insurance option.

This choice of a private insurance option, which exists today under Medicare, has largely disappeared from the debate over Medicare for All. But having a private insurance choice in Medicare is likely to make the possibility of a Medicare for All proposal more popular over time. It could evolve into a “Medicare as it is today for all” program, with most people having a Medicare card but with supplemental private insurance or a completely alternative private plan available to them. It is important to recognize that this would be a Medicare for All–type program, but not a single-payer program.

One thing we have learned from decades of health care reform debates is how uncertain predictions are about the future in either health care or politics in general. However, this direction for the debate is what we believe is suggested by examining the underlying polling results and the changing composition of the Democratic Party. Regardless of the outcome of the Medicare for All debate in the short term, these findings suggest that we are likely to see future Democratic presidential and congressional candidates putting forward versions of a Medicare for All bill, which means the future of health care reform in the US will remain unsettled.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: Robert J. Blendon, ScD, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, 4th Floor, Boston, MA 02115 (rblendon@hsph.harvard.edu).

Conflict of Interest Disclosures: Drs Blendon and Benson reported receiving grants from the Commonwealth Fund, nonfinancial support from the New York Times, and personal fees from the American Hospital Association.

Acknowledgment: This work was supported by a grant from the Commonwealth Fund. Nonfinancial support was provided by the New York Times.

Kaiser Family Foundation. KFF health tracking poll—February 2020: health care in the 2020 election. Accessed March 12, 2020. https://www.kff.org/health-reform/poll-finding/kff-health-tracking-poll-february-2020
New York Times, Commonwealth Fund, Harvard T.H. Chan School of Public Health. Public attitudes about Medicare-for-All, by age, 2019. Accessed March 12, 2020. https://cdn1.sph.harvard.edu/wp-content/uploads/sites/94/2020/03/NYTimes-Commonwealth-HSPH-M4A.pdf
Hart Research Associates. NBC News/Wall Street Journal survey, December 14-17, 2019. Accessed March 12, 2020. https://assets.documentcloud.org/documents/6588056/19504-NBCWSJ-December-Poll.pdf
Commonwealth Fund, New York Times, Harvard T.H. Chan School of Public Health. Americans’ values and beliefs about national health insurance reform. Accessed March 12, 2020. https://cdn1.sph.harvard.edu/wp-content/uploads/sites/94/2019/10/CMWF-NYT-Harvard_Final-Report_Oct2019.pdf
Saad  L, Jones  JM, Brenan  M. Understanding shifts in Democratic Party ideology. Accessed March 12, 2020. https://news.gallup.com/poll/246806/understanding-shifts-democratic-party-ideology.aspx
Blendon  RJ, Benson  JM.  Public opinion at the time of the vote on health care reform.   N Engl J Med. 2010;362(16):e55. doi:10.1056/NEJMp1003844PubMedGoogle Scholar
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