How Democrats’ disagreement over health care is splitting the primary

As Democrats push forward in the fight for the party’s presidential nomination, one issue is at the top of voters’ minds: Health care.

Both the New Hampshire primary exit polls on Tuesday and the Iowa caucus entrance polls last week showed that health care has been a key priority. But these voters remain divided over what the future of health care should be — shifting to a government-run Medicare-for-All-style system or shoring up the current programs, primarily Obamacare.

That split is a key reason the party is fracturing over the question of who should be the Democratic nominee against President Donald Trump, who continues to undermine the Affordable Care Act and Medicaid.

More than one-third of Democratic voters going to the polls in New Hampshire’s first-in-the-nation primary said health care was the most important issue in determining their vote, beating out climate change, income equality and foreign policy.

Vermont Sen. Bernie Sanders was the clear favorite among this group, drawing support from about one-third of voters, according to exit polls.

Former South Bend, Indiana, Mayor Pete Buttigieg and Minnesota Sen. Amy Klobuchar each attracted about 1 in 5 of these voters, while former Vice President Joe Biden and Massachusetts Sen. Elizabeth Warren, who have also campaigned on health care, landed in the single digits.

Six in 10 voters supported a single-payer system — with Sanders attracting close to 40% of those voters and Buttigieg attracting more than 2 in 10. Among those who oppose single-payer, more than 3 in 10 backed Buttigieg and more than a quarter voted for Klobuchar. Biden received 13% of the vote, while Sanders and Warren were in the single digits.

The Granite State vote came a week after Iowa caucusgoers affirmed that health care was the most important issue for choosing a nominee. But the 42% of respondents who picked health care in Iowa were split between Sanders and Buttigieg, with about a quarter supporting each. Almost 2 in 5 supported Warren while 1 in 6 backed Biden and the same for Klobuchar.

Almost 3 in 5 Iowa Democratic caucusgoers supported replacing private health insurance with a government plan, with the rest opposing it.

Shaping 2020 from the start

Health care has been at the forefront of the campaign since the beginning, but the party is split between radically overhauling the nation’s health insurance system or taking smaller steps.

Sanders, an independent, has led the fight to create a national, single-payer government plan, called “Medicare for All.” It would essentially replace private insurance, providing sweeping benefits at no cost to patients.

But its price tag — estimated at around $32 trillion over 10 years — has spooked many people, providing a line of attack by rivals Biden and Buttigieg.

While Sanders has acknowledged he’d have to raise taxes on the middle class, he hasn’t laid out specifically how he would cover the tab.

Providing a detailed financing plan for Medicare for All may have contributed to the decline of Warren’s popularity. Her poll numbers took a nose dive after she laid out a proposal in November that called for states, employers, corporations and the wealthy to pay for the single-payer system, which she also supports.

Meanwhile, moderates such as Biden, Buttigieg and Klobuchar favor building on the Affordable Care Act. They would add to the Obamacare exchanges a government-backed public option, which would presumably have lower premiums and would compete with the private insurers. They would also boost federal subsidies so more people could afford coverage.

What happens next

Looking ahead, the candidates are entering very different terrain. The next stop is Nevada, which has a large unionized casino industry. Sanders and Warren have had some trouble garnering support from certain unions, who typically fight hard for premium health benefits. They aren’t as eager to give them up in exchange for a government plan, even though the senators have said they’d press employers to give workers higher wages in exchange.

The Culinary Union, which represents 60,000 hotel and casino workers and has a long history fighting for their health care, is circulating fliers that warn against supporting Sanders and Warren, saying they will end or replace Culinary Healthcare, while the other candidates will “protect” it.

Biden, in particular, has hit Sanders on the impact of Medicare for All on union plans.

While the path ahead for the Democratic candidates remains in flux, there’s one party leader who is maintaining a steady course ahead of the November election.

House Speaker Nancy Pelosi is setting up her lawmakers as protectors of the Affordable Care Act and of people with pre-existing conditions, following the program laid out in 2018, when Democrats’ defense of the law helped them take back control of the House amid Republican efforts to repeal it.

The House has since joined a coalition of Democratic state attorneys general who are defending the landmark health reform law in a lawsuit filed by a group of Republican state attorneys general and backed by Trump’s Justice Department.

Pelosi also spearheaded legislation that aims to lower drug costs by letting the federal government negotiate prices of certain medications with manufacturers. The bill is not expected to advance through the Senate.