In last week's Democratic presidential debates, both nights began with a discussion of health care, and the issue received more time than any other. Most Democrats believe that Republican attempts to repeal the Affordable Care Act (ACA) backfired, resulting in the Democrats retaking the House of Representatives in 2018. Back in 2010, the passage of the ACA is what cost Democrats control of the House. So it is vital that the party's candidates learn how to discuss this issue that has become a third rail in national politics.
Very few decisions in Washington so directly impact people's lives as decisions about health care policy. In 2010, the Republicans effectively scared people into thinking that the ACA was going to change their health care coverage. People complain about their insurance, they bemoan the premiums and the copays and the deductibles, but at least they know it is there. Change suggests uncertainty, and no one wants to feel uncertain about their coverage. As well, President Barack Obama told a big fib to get the bill passed: "If you like your coverage, you can keep your coverage," he said versions of repeatedly. But health care coverage changes all the time. It changed before the ACA was passed, and it changed after the ACA was passed. The political difference was that any regrettable changes after passage were blamed on the ACA whether the law was at fault or not.
People's health insurance policies still change all the time, and it is not the individual making decisions for her family but the boss making decisions for her company. The workers may or may not like those changes. Only if health care has been subject to union contract negotiations do workers have any say in the changes. The only constant is that copays and deductibles almost never go down, only up. So this is the first lesson for politicians discussing health care: Do not start by arguing about the systems other countries have, or by making an ideological point about which policy approach is the most liberal or the most popular. Start by describing the system as it is today, the situations and frustrations people find themselves facing, the rising costs, the lack of choice. Politicians need to ground their prescriptions for change in the observations of regular people they meet on the campaign trail.
During the debate about the ACA, the Republican mantra was "no government-run health care." Of course, even Medicare for All, which would create the largest degree of government involvement, would not result in "government-run health care." The government is not going to run the hospitals and clinics. It is not going to hire doctors. It is going to pay the bills. That is "government-run bill paying."
This leads to another key point: When the Republicans attack Medicare for All as "socialist medicine" or when Democrats attack it because it would restrict people's choices, candidates who support it should say, "Don't take my word for it — ask your grandmother. Does she like Medicare? Does she get to pick her doctor? Does she like not having to worry about the bills?" Nobody trusts politicians, but they tend to trust grandma, and I have yet to meet a grandma who does not love Medicare.
Another way to build trust and dispel fear-mongering is to appeal to history, and this goes for other policies such as making public colleges free. When Franklin Roosevelt called for Social Security, people said he was a socialist, but he was really a pragmatist: He saw millions of poor elderly and found a way to alleviate their poverty. When Lyndon Johnson passed Medicare and Medicaid, opponents called it socialized medicine, but he saw old people and poor people unable to get health care, and he found a pragmatic way to provide it. Introducing a note of pragmatism, and not only rhetorically but in implementing a policy like Medicare for All, is vital. It robs opponents of the charge that this policy is some half-baked idea only an academic or a radical could like. FDR repeatedly spoke about his policies as bold "experiments." If they did not address the problem, he was prepared to try something else. This put the burden back on the opponents: What were they planning to do to address a particular problem? The American people like politicians who are problem solvers. They resist politicians who are ideologues.
There is an easy way to introduce this note of pragmatism without sounding like a waffler. Many union members have "Cadillac plans" that were the result of contract negotiations: They gave up wage increases in order to secure better benefits. A Democratic politician can argue that unions can keep their policies until they get a chance to renegotiate their contracts. Employers, freed from the need to pay for health care, can provide higher wages. I think that it would also make sense for Democrats advocating Medicare for All to acknowledge that there will always be room for private insurance because most people get supplemental insurance if they have Medicare.
There are other, less central arguments that can be used to bolster the case. For example, Medicare for All would actually increase consumer choice because all doctors would be "in network." And, perhaps not on a debate stage but in a major address, a candidate could point out that while markets are wonderful in certain areas of life, such as choosing the refrigerator that works for you, or the car you want to drive, when you have a heart attack, you don't have a chance to shop around for the best emergency room. And while most businesses focus on getting repeat customers, the health care industry aims at the exact opposite, so a market approach always seemed like a bad fit to begin with.
As for the moral necessity of universal coverage, I wish we lived in a country that adhered closely to Catholic social teaching that considers health care a basic human right, but we don't. I am not sure if anyone has polled the specific question of guaranteeing health care to undocumented immigrants, but I am pretty sure it would not be a political winner even if it is, from a moral perspective, an easy call. Still, covering everybody just makes sense: It doesn't help anyone when a bunch of sick people are running around our schools or workplaces. And here, a little Scripture might be helpful: The parable of the Good Samaritan is precisely on point.
Last Tuesday, we saw Democratic candidates engaged in a robust debate about how to help people get health insurance. Wednesday night was nastier, more Trump-like, as the candidates seemed intent on figuring out how to deliver the next insult. All Democrats should grant the good faith of each other's arguments and go no further in criticizing each other's plans than: "I hear you, but I just don't think your approach will work."
There is no issue that is more personal to more people than heath care. Democrats need to talk about it in ways that inoculate them from the expected arguments for the status quo. That discussion has to stay close to people's actual lived experience, their frustrations and their fears. In 2010 and 2018, we learned that it is a lot easier to keep things as they are in this area than to introduce change. Just as there is a moral obligation to provide health care to all who need it, there is a moral obligation to be intelligent in how they advocate for change.
[Michael Sean Winters covers the nexus of religion and politics for NCR.]