Prominent Democratic leaders are sounding increasingly vocal alarms to try to halt political momentum for “Medicare for all,” opting to risk alienating liberals and deepening the divide in the party rather than enter an election year with a sweeping health care proposal that many see as a liability for candidates up and down the ballot.
From Michigan to Georgia, North Dakota to Texas, Democratic elected officials, strategists and pollsters are warning that the party’s commitment to the Obama-era Affordable Care Act — widely seen as critical to electoral gains in 2018 and 2019 — could slip away as a political advantage in 2020 if Republicans seize on Medicare for all and try to paint Democrats as socialists on health care.
“When you say Medicare for all, it’s a risk. It makes people feel afraid,” said Gov. Gina Raimondo of Rhode Island, who headed a successful national effort as chairwoman of the Democratic Governors Association, to win governor’s mansions in Kentucky and Louisiana this month. “We won in Kentucky and Louisiana, barely, in part, because we won on health care. I don’t think we can afford to lose on health care.”
While Democrats won the House in 2018 by decrying Republican efforts to undercut popular provisions in the Affordable Care Act, the Democratic presidential primary race has turned in large part on whether to replace that law with a more expansive, single-payer system, financed by higher taxes and linked to an end to private health insurance.
The two liberal candidates pushing Medicare for all, Senators Bernie Sanders and Elizabeth Warren, have highly energized supporters who want this form of universal health care, and collectively garner about 40 percent of the vote in most polls. More moderate leaders in the race, like Joseph R. Biden Jr., the former vice president, and Pete Buttigieg, the mayor of South Bend, Ind., support adding a public health care option to the current law. While the primary race is fluid and unpredictable, Medicare for all has steadily driven much of the Democratic discussion of health care.
A determination to shift those conversations is now spurring top Democratic officials to speak out more forcefully against Medicare for all, playing to the anxieties of Democrats who fear their party could once more lose crucial Electoral College battlegrounds like Pennsylvania, Michigan and Wisconsin to Mr. Trump if they push for a nationwide overhaul of health care coverage and benefits.
Warnings are being issued at all levels of the Democratic Party, from union members who fear losing hard-won benefits, to candidates running in swing districts, all the way up to former President Barack Obama, who offered a pointed warning about the risks of overreach at a gathering of donors in Washington, D.C., this month. People close to the former president said his remarks were rooted in his experience passing the health care law, which prompted his concerns about how willing voters would be to embrace an even more sweeping change.
House Speaker Nancy Pelosi was even more critical this month: “I’m not a big fan of Medicare for all,” she told Bloomberg Television.
Privately and publicly, party strategists focused on the nation’s most competitive House and Senate seats next cycle are frustrated that conversation in the Democratic presidential race often devolves into arcane debates about Medicare for all, rather than last year’s easier-to-grasp message about protecting people with pre-existing conditions. Many are gravely concerned about the impact that having a presidential nominee who backs Medicare for all at the top of the ticket would have on the most vulnerable Democratic candidates.
Tyler Jones, a South Carolina Democratic strategist who helped flip a Charleston district previously held by Republicans for nearly four decades, worries that having a presidential nominee who backs proposals like free college and single-payer health care would cost the party up and down the ballot.
“If we have a nominee that supports Medicare for all at the top of the ticket, our majority in the House is in serious jeopardy, not to mention a potential majority in the Senate,” said Mr. Jones, who is unaffiliated with a presidential campaign after advising former Representative Beto O’Rourke. “That is not a smart strategy.”
Liberal supporters of Mr. Sanders and Ms. Warren offer a different political analysis of the party’s 2016 loss, saying that it was the failure to energize voters with a bold new vision that cost Democrats the presidency. They argue that polices like Medicare for all, can create a winning coalition by motivating independents who feel alienated by the political system and by energizing Democrats.
On the campaign trail and in debates, Ms. Warren pitches her health care plan by arguing that the current system is failing many Americans, even those who have health coverage, because of high costs. She says she’s asking corporations and the richest Americans to pay more to create a system in which people would no longer face the risk of financial ruin because of medical bills.
While she shies away from offering the kind of explicit political analysis frequently used by her rivals, Ms. Warren argues that the more Democrats talk about what’s broken with the system, the more support for Medicare for all will build. Aides point to polling by the Kaiser Family Foundation showing that a majority of all Democrats and about half of independents favor a national Medicare for all plan.
“We’re not there because we need to be out talking about people’s experiences right now,” she told reporters in New Hampshire.
Yet, as the race moves closer and closer to the start of primary voting, other polling indicates that voters in key battleground states have grown more skeptical of implementing Medicare for all. A survey released this month by the Kaiser Family Foundation and Cook Political Report found that nearly two-thirds of swing voters in Michigan, Minnesota, Pennsylvania and Wisconsin rated a Medicare for all plan that would eliminate private insurance as a “bad idea.”
Internal polling conducted by the Democratic Governors Association in October found that Gov. John Bel Edwards of Louisiana tested 15 points higher on health care than his Republican challenger. Their polling found similar results in Kentucky, where Andy Beshear, the Democratic candidate and now governor-elect, polled 12 points higher than Gov. Matt Bevin, a Republican.
Many Democrats dismiss the idea that Ms. Warren could pivot to a more centrist message in the primary campaign, as candidates typically do after winning the nomination, pointing to how central Medicare for all has become to her message.
“The one thing I do know about Elizabeth is she’s highly principled,” said former Senator Heidi Heitkamp, who served with Ms. Warren in the Senate. “She’s going to run with that the whole way through. People who think there’s a pivot coming from her just don’t know her.”
Even if Ms. Warren or Mr. Sanders fail to win the nomination, some Democrats from battleground and conservative states worry that the party has already damaged its brand heading into the general election.
“The politics are horrible for the Democratic Party, that’s my judgment,” said Ms. Heitkamp, who lost her seat representing North Dakota last year and is now heading up an effort to win rural voters. “We’re making the issue about our plan rather than what the president has or has not done.”
Senator Sherrod Brown of Ohio, who has said it would be a “terrible mistake” for the party nominee to support Medicare for all, is urging Democrats to embrace a more unified message against Mr. Trump. That feels unlikely in the midst of a heated primary campaign where health care has emerged as a significant difference between the candidates.
“Democrats need to start talking about the contrast with Trump on this,” said Mr. Brown, who has not endorsed a candidate in the primary race. “The conversation should not be Democrats fighting over the path to universal coverage.”
Congressional candidates are frequently asked whether they agree with the policy; candidates in all 10 of the most competitive Senate races have said they do not support it, preferring to keep their health care message focused on expanding Medicaid, protecting the Affordable Care Act and slamming repeal efforts by Republicans.
“Texans kind of don’t like to be forced into anything,” said M.J. Hegar, a Democrat running in a Senate primary in Texas. “They feel, we feel, that we are a nation and a state of freedom and choices, and that’s a big part of why the majority of Texans want a public option.”
Senator Doug Jones, an Alabama Democrat who has endorsed Mr. Biden, sought to cast himself as a check on any Democratic president who would pursue Medicare for all, a proposal that voters in his conservative state view with deep antipathy.
“If a Democrat is elected president, that Democrat is going to have to talk — not only try to reach across the aisle to Republicans to get things done — they’re going to have to also talk to Democrats like me that are more moderate,” said Mr. Jones, who is often considered the most endangered Democratic senator in the country.
Other allies of Mr. Biden have begun speaking in increasingly apocalyptic terms about how a presidential nominee perceived as too far to the left — thanks to positions on issues like health care — would impact other candidates in competitive races.
“I care about the down-ballot carnage that would result,” said Representative Cedric Richmond, a Louisiana Democrat and co-chairman of Mr. Biden’s campaign.
There’s some data to support those worries: A new analysis of the 2018 elections found that Democrats who supported Medicare for all in the closest House races did worse than those who did not. In 60 districts examined by Alan Abramowitz, an Emory University political science professor, just 45 percent of Democratic candidates who publicly supported Medicare for all won in 2018 while 72 percent of Democrats who did not support the legislation won.
“We’ve got to find ways that we can build on the success of the Affordable Care Act and ensure that everyone has coverage that works for them,” said Representative Chris Pappas, a New Hampshire Democrat elected last year. “Most of us who were recently elected to Congress, those who helped flip the majority in the House, really have a practical point of view of what’s actually going to deliver relief to families in our districts.”