For the presidential candidates of the US Democrats, there will presumably be only one decisive issue in the coming months: the impeachment proceedings against US President Donald Trump. Away from the Ukraine affair, however, another debate is smoldering, which could pick up speed in the beginning of the election campaign. It's about health policy. Many Democrats, including prominent presidential candidates Joe Biden, Bernie Sanders and Elizabeth Warren, want a radical break with the current health care system: they are fighting for "health insurance for all".
The politicians make a risky bet, say health experts. Because no one knows if this idea will not catapult the Democrats in the presidential election in November 2020. The issue is urgent enough: More than 30 million Americans have no health insurance, and the majority of the population is dissatisfied with the existing system. It is more expensive per capita than in any other western country, but produces significantly worse results.
The proposals of the Democrats therefore involve a fundamental change. It's not just about getting the health insurance law from former President Barack Obama, which Donald Trump wants to do away with. Obama's "Affordable Care Act," also known as "Obamacare," has helped provide 20 million more people with health coverage than in 2008 - at that time, 50 million Americans were uninsured.
However, the structure of the US healthcare system has not affected "Obamacare": most Americans who currently have insurance cover it through private companies. Only people over the age of 65 or with low income can access government insurance programs such as Medicare.
Many Democrats now want a "Medicare for all": Every American would be assured by the same, legally prescribed program, the membership would be mandatory. The proposal reminds a little of the idea of the so-called citizen insurance, which brought the SPD in the 2017 general election campaign. Other Democrats want a system in which citizens can continue to insure themselves privately, but can also participate in a state, statutory insurance - an idea that is similar to today's German system.
No more "too radical"
The different approaches are particularly clear among the three candidates who are leading the polls:
- Self-styled Socialist Bernie Sanders, Vermont Senator, and Massachusetts Senator Elizabeth Warren are on the Progressive side. Sanders was the first to make "Medicare for all" a central theme in his election campaign; Warren also supports it now.
- Ex-vice-president Joe Biden shows more moderate: He wants to expand "Obamacare" by a legal option. It would give it the opportunity to be insured by law - but no obligation. A suggestion strongly criticized by the Sanders group: Biden's plan would mean that around ten million people would remain without insurance.
The fact that Biden's position in the USA is considered moderate today shows how much public perception has changed since Obama. "Biden's proposal would have been one of the ideas most strongly rated socialist in the debate on the Affordable Care Act," said Larry Levitt, vice president of the Kaiser Family Foundation, a nonpartisan research organization specializing in health issues. At the time, the call for legal insurance was dismissed as "too radical," recalls Celinda Lake, a pollster from the US Democrats. In Congress, the idea was finally buried after the electoral victory in 2009.
Charlie Neibergall / AP
Elizabeth Warren: Is one of the progressive advocates of a citizens insurance
According to the experts, the shift in political discourse is due in particular to Sanders' election campaign in 2016 - but partly to the Republican attempts to abolish "Obamacare". For the majority of the population, the Conservatives have come down poorly with this push - one of the reasons why the US Democrats won the House of Representatives majority in the 2018 Midterm elections. Surveys by the Kaiser Family Foundation show that "Obamacare" became more popular the more the Republicans opposed it. More than half of Americans today support the law.
Health more confidence in the Democrats
Many progressives felt encouraged to go further, says Levitt. But has the political opinion of Americans on healthcare really changed so much that the Democrats with their insurance can score for everyone in the election campaign? The Republicans would continue to denounce the plans as "socialism," says Levitt - a term used with fear and prejudice for the majority of skeptical US citizens over state-sponsored conduct.
According to the polls, many voters are initially positive about the slogan "Medicare for All". But he loses his consent when people hear that it could go along with tax increases or they no longer have the freedom to choose private insurance. After all, who chooses the Democrats supports the general idea of a general health insurance. When it comes to health issues, Americans would have more confidence in the Democrats than in the Republicans, says Celinda Lake. The mostly election-critical "Independents", which can thus be assigned to neither of the two major parties, but are more hesitant when it comes to a drastic change.
Obamacare could be abolished in the middle of the election campaign
Joe Biden's modest attitude could win those voters who shy away from overly big changes. Sanders and Warren could benefit if their polarizing plans basically drove more people to the ballot box - since 1968, turnout in the US has never been higher than 60 percent.
JOSEPH PREZIOSO / AFP
Joe Biden: Could score with his moderate suggestions
But it also depends on how convincingly a presidential candidate or presidential candidate appears after the primaries. In the "Primaries", leftist candidates can rely on their traditional constituency. In the presidential election, if they play against Donald Trump, they must appeal much more to the center.
In the past, therefore, candidates who initially spoke out in favor of a legal insurance policy repeatedly staggered back to address the masses. Such a change of course is possible with some of the current candidates, except Bernie Sanders.
However, external circumstances could also fundamentally change the debate: "Obamacare" is a lawsuit filed by several republican-ruled states that could make it to the Supreme Court. The White House refuses to defend the law, even though it is one of the government's responsibilities to stand trial for former president prescriptions. It is quite possible that a verdict will be pronounced in the summer of next year, in the middle of the final phase of the election campaign.
Johannes EISELE / AFP
Bernie Sanders: Provided in the 2016 election campaign for broader acceptance of government regulations
Should the conservatively enforced Supreme Court "Obamacare" abolish without alternative, it would cause chaos: Millions would be there without health insurance. Paradoxically, this might be an opportunity for candidates who propose a whole new model.
The question is therefore how Donald Trump will behave in the election campaign. So far, the US president has not presented a new strategy for health care, although he once promised it in the election campaign. His government has so far been limited to deregulating private insurance. Trump will highlight tax cuts and other cost reductions and attack "Medicare for all" as "state health insurance," says Jim McLaughlin, a Republican pollster. It remains to be seen whether this still sounds like an insult to the majority of Americans.