When Americans are asked whether they support a “Medicare for all” system that would replace all current insurance with a generous government program, a majority often say yes. But when they’re asked follow-up questions, they often reveal that they’re not familiar with the details of that plan — or that they would also be happy with other Democratic policy proposals.
In a new survey from The New York Times as well as the Commonwealth Fund and the Harvard T.H. Chan School of Public Health, we forced the issue. We asked a panel of 2,005 adults to pick their favorite plan from three choices. One resembled the Medicare for all proposal; one was like more incremental Democratic proposals; and one was like a plan proposed by congressional Republicans, which would reduce federal involvement in the health system and give more money and autonomy to states.
The share of the public supporting each option wound up being almost identical — around 30 percent each.
That means that most Americans support Democratic approaches to changing the health care system. But that group is about evenly split between an expansive set of changes under the Medicare for all proposal favored by Senators Elizabeth Warren and Bernie Sanders, and a less sweeping overhaul that would simply move the country closer to universal coverage, such as those from Joe Biden and Pete Buttigieg. (Not every politician’s health plan fits neatly in these categories. Kamala Harris, for example, has proposed a system that would eliminate most existing insurance arrangements, but replace them with a system with both public and private coverage options.)
So what are people really saying when they say they like Medicare for all?
They don’t like the health system
The group that preferred Medicare for all was more disgruntled with the current system than other groups, and more comfortable with drastic change. Only 21 percent said they thought the United States had the best health care system in the world, compared with 55 percent among those supporting the Republican plan. Majorities of the Medicare for all group said they were dissatisfied with the cost of their health care and worried about their ability to pay if they became ill in the next year. Still, a majority of this group also said they were satisfied with the quality of their care and their current insurance.
Robert Blendon, a professor of health policy and political analysis at the Harvard School of Public Health, who helped write the study, said the overlap between dissatisfaction and support for the proposal showed that Medicare for all’s strong supporters understand that it would cause substantial disruption of the current system. Critics have said that the proposal goes too far because it would involve eliminating most private health insurance and could reshuffle the finances of major health care companies.
“There’s no question that the level of dissatisfaction leads to interest in big proposals,” he said, describing their perspective. “When I’m really dissatisfied, I’m interested in Canada. I want to do big new things.”
The Republican proposal would also cause large disruptions in the system, upending the current Medicaid expansion and the markets for people who buy their own insurance. The survey respondents who favored that plan seemed largely satisfied with the status quo. That may be because they do not think those changes will affect them personally. It may also be because a Republican is in the White House now, so the status quo seems rosier to them than it did a few years ago.
They think taxes are a fair trade-off for coverage
Supporters of Medicare for all were more approving of socialism and showed stronger support for the notion that the government should be responsible for ensuring universal access to health care for all Americans. When asked if they were comfortable paying higher taxes in exchange for health coverage for everyone, 79 percent said they would be willing, a substantially higher proportion than respondents in the other two groups.
Those findings suggest that critiques based on the high cost of the proposal probably won’t do much to deter its strongest supporters. But the idea of higher taxes was less popular over all. Fifty-three percent of all respondents said they would personally pay more taxes so that everyone could have health care. Only 23 percent of those favoring the Republican plan said they would.
They think the government should play a bigger role
All three groups showed consensus on some points. Large majorities thought the government should require insurers to continue offering coverage to people with pre-existing health conditions. That answer, consistent with some other recent surveys, represents a shift. The Affordable Care Act first provided robust consumer protections for such people, and as recently as two years ago, most Republicans in Congress voted for legislation that would have substantially weakened those protections. Obamacare itself now consistently enjoys majority support in surveys, after years of being under water.
“Protection for people with pre-existing conditions is the status quo, and it can’t be taken away except at a huge political cost,” said David Blumenthal, the president of the Commonwealth Fund.
There was also relatively broad agreement that health care is a right. When asked whether all Americans should have a right to health care regardless of their ability to pay, nearly 80 percent of all respondents agreed. Sixty percent of those favoring the Republican health plan believed health care was a right, but among those favoring the two Democratic proposals, support exceeded 90 percent.
Where the groups differed was in how a universal health care system should be achieved. Eighty-five percent of the Medicare for all enthusiasts thought it was the responsibility of government to ensure all Americans had health coverage. Only 73 percent of those supporting more incremental Democratic reforms agreed. Among those supporting the Republican plan, the number was 20 percent. Sixty-five percent of people in that group said the government should become less involved in health care in the future.
Will their ranks grow?
On many questions about policy and values, there was broad overlap between the supporters of Medicare for all and supporters of a more incremental approach to coverage expansion. And many survey respondents struggled to express a strong preference between the two choices.
Those factors lead Mr. Blendon to believe there are immediate opportunities for Democrats to devise a plan with broad appeal. The underlying shared values endorsed by supporters of both Democratic approaches — about rights to health care, protections for the sick, and a larger role for the government in ensuring equity — could be paired with a more modest set of policy changes.
In the long term, however, the appeal of Medicare for all may hinge on how well the current health care system serves the public. Recent research has found that employer health plans, the most common and popular form of health insurance for working-age Americans, have become substantially less affordable. More Americans are now what experts call “underinsured,” meaning that their coverage still leaves them exposed to a damaging financial hit if they get sick. If those trends continue, a greater share of Americans may find themselves dissatisfied with the system and fearful about how it will treat them if they need it.
“Most Americans want everyone to have coverage, but some people are willing to sacrifice more to get there than others,” Mr. Blumenthal said. “The people who are willing to sacrifice more are the people who have less to lose.”
If the status quo gets bad enough, the number of people seeking big changes could grow.