Unlike Medicare for All, Medicare for Americawould preserve premiums and deductibles andalso allow private insurers to operate Medicare plans.(Photo: Shutterstock)

As Democratic presidential primary candidates try to walk apolitical tightrope between the party'sprogressive and center-left wings, they face increasing pressure tooutline the details of their health reform proposals.

On Wednesday, Sen. Bernie Sanders (I-Vt.) reaffirmed his stanceby reintroducing a “Medicare for All” bill, the idea thatfueled his 2016 presidential run.

As with its previous iterations, Sanders' latest bill would establish a national single-payer“Medicare” system with vastly expanded benefits, prohibit privateplans from competing with Medicare and eliminate cost sharing. Newin this version is a universal provision for long-term care in homeand community settings (but Medicaid would continue to coverinstitutional care).

Already, it has an impressive list of Senate cosponsors —including Sanders' rivals for the Democratic presidentialnomination, Cory Booker (D-N.J.), Kirsten Gillibrand (D-N.Y.),Kamala Harris (D-Calif.) and Elizabeth Warren (D-Mass.).

Related: Medicare for All: Where the 2020 presidentialcandidates stand

But many of the candidates — even official Medicarefor All co-sponsors — are at the same time edging toward amore incremental approach, called “Medicare for America.”Proponents argue it could deliver better health care to Americanswhile avoiding political, budgetary and legal objections.

It comes as politicians tread carefully over the political landmines a Medicare for All endorsement could unleash, whileseeking to capitalize on a growing appetite for health reform.

During the 2018 midterm election campaigns, some congressionalcandidates talked about allowing people older than 55 to joinMedicare, or allowing people younger than 65 to buy into it if theychoose (the “public option”). Many aren't eager to face theindustry opposition that a full-on Medicare expansion would surelytrigger.

From the consumer perspective, sweeping reform poses a risk.Despite Medicare's popularity with its beneficiaries, the majorityof Americans express satisfaction with their health care, and manyare nervous about giving up private options. Also, many analystsare worried that a generous Medicare for All planthat promises everything would break the bank without any patientpayments.

That tension is pushing a number of candidates toward theemerging “Medicare for America” option. The bill was introducedlast December to little fanfare by two Democrats, Rep. Rosa DeLauro(Conn.) and Rep. Jan Schakowsky (Ill.). It hasn't been reintroducedin the new Congress.

This proposed system would guarantee universal coverage, butleaves job-based insurance available for those who want it. UnlikeMedicare for All, though, it preserves premiumsand deductibles, so beneficiaries would still have to pay somecosts out-of-pocket. It allows private insurers to operate Medicareplans as well, a system called Medicare Advantage that covers abouta third of the program's beneficiaries currently, and which wouldbe outlawed under Medicare for All.

“Before policies get defined, what you see is people endorsing aplan that is a little, perhaps, less subject to early attack,” saidCelinda Lake, a Democratic pollster. “A lot of candidates feel ifthey endorse a plan that leaves some private insurance, they getmore time to say what their ideas are about.”

“Medicare for America” got its first high-profile endorsementfrom former Texas Rep. Beto O'Rourke, who launched his own 2020 bidin mid-March. Other candidates — including Warren, Gillibrand andPete Buttigieg, the mayor of South Bend, Ind. — have tiptoed towardit without making any endorsements, suggesting they backMedicare for All in theory but also support asystem that retains private insurance, at least temporarily.

Such an approach is perhaps unsurprising. Pollingindicates voters want strong health reform. Candidates, electionexperts say, need something powerful to deliver.

Improving the Affordable Care Act, an idea backed by Sen. AmyKlobuchar, a Minnesota Democrat running in the primary's moderatelane, may not suffice.

“The ACA is popular at the 50 percent level, but it's notenergetic. It doesn't get people who really like it,” Blendon said.“What they're looking for is something that is exciting but isn'tthreatening.”

Both Medicare for All and “Medicare forAmerica,” experts noted, offer something that presidentialcandidates can campaign on and a health alternative that at firstblush sounds appealing to many. But the latter could skirt somepotential obstacles.

Approval for Medicare for All drops whenpeople learn that, under such a program, they would likely losetheir current health plan (even if the government-offered plancould theoretically provide more generous coverage).

The cost-sharing element of “Medicare for America,” meanwhile,would ostensibly quiet some of the concerns about paying forMedicare's expansion, though critics on the left worry it wouldmean some people would still be unable to afford care.

This also tracks with recent polling which suggests that, whileMedicare for All support can be swayed, voters ofall political stripes favor somesort of way to extend optional Medicare coverage, without necessarilyeliminating the private industry altogether.

Employers would have to offer plans that were at least asgenerous as the government program, or direct employees toMedicare. Employers who stop offering health benefits would have topay a Medicare payroll tax.

For now, most candidates are still avoiding a concrete stance on“Medicare for America.” Despite signs of interest, the Buttigieg,Gillibrand and Warren campaigns all declined to directly answerquestions about whether they endorse “Medicare for America.” Thecampaigns of other candidates in the race — Harris, Klobuchar,Booker, former Housing and Urban Development Secretary JulianCastro and Washington Gov. Jay Inslee — similarly declined tocomment.

Reading between the lines, though, their promises to achieveuniversal health care by expanding Medicare — while retainingprivate insurance — leaves them few options besides something like“Medicare for America,” argued one of its main architects.

“There are variations besides this particular plan, but once youstart to actually dig into this, if you want universal coverageyou're going to have to do the kinds of things” spelled out in“Medicare for America,” argued Jacob Hacker, a political scientistat Yale University, who played a lead role in devising thisproposal.

Still, though, it has prompted objections from both the left andthe right.

On the far left, the cost sharing is a dominant concern. (Under“Medicare for America,” an individual would have a $3,500out-of-pocket limit; a family would have a $5,000 limit. Premiumswould be capped at almost 10 percent of a household'sincome.) Those critics also say the plan's accommodations toprivate insurance limit the government's ability to negotiate lowerprices.

Conservatives repeat many of the arguments levied againstMedicare for All — too expensive, toodisruptive.

Hospitals, insurance, drugmakers and doctors, who have alreadymobilized against Medicare for All, also can beexpected to make just as strong a showing against “Medicare forAmerica,” political analysts said. More Medicare means less revenuefor the medical industry.

Said David Blumenthal of the Commonwealth Fund: “The fact ofexpanded Medicare will be the focus of attacks.”

Kaiser HealthNews (KHN) is a national health policy news service. It is aneditorially independent program of the Henry J. Kaiser Family Foundation whichis not affiliated with Kaiser Permanente.

Read more: 

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