What Kamala Harris learned from embracing, abandoning Medicare-for-all
Standing on a Miami debate stage five years ago and seeking the presidency, Kamala Harris raised her hand and joined a pledge to abolish private health insurance in favor of a government-run plan.
Harris, then a Democratic senator from California, later said she misunderstood the moderator’s question, clarifying that she would abolish her own private health insurance - not every American’s. The moment was one of Harris’s stumbles in 2019 as she struggled to navigate Democrats’ fight over Medicare-for-all, the transformative proposal to provide government health coverage to all Americans, and explain her own evolving position.
Harris first embraced a plan in 2017 by Sen. Bernie Sanders (I-Vt.) to remake the nation’s health system and eliminate private insurance, a proposal that worried many Americans who feared losing access to their doctors. But after the blowback following her June 2019 debate pledge, Harris a month later offered her own compromise plan that would have preserved a role for private health insurance and more slowly phased in the changes that Sanders wanted, exposing Harris to attacks from Sanders supporters and other liberals who deemed her insufficiently progressive.
Now the Democrats’ nominee for president, Harris rejects Medicare-for-all altogether, saying she plans to build on the nation’s existing health-care system rather than replace it. But as she seeks the presidency again, aides are bracing as her earlier Medicare-for-all pledges have been revived by rival Donald Trump and became a focus on prime-time television.
“I absolutely support - and over the last four years as vice president - private health-care options,” Harris said at the presidential debate Tuesday, responding to a moderator’s question about her past support for ending private health insurance. “But what we need to do is maintain and grow the Affordable Care Act,” she quickly added, highlighting her current position.
The Harris campaign and her White House office acknowledged that Harris’s health-care positions have shifted since her last bid for the presidency. In interviews, officials said her previous support for Medicare-for-all and current pledge to build on private health insurance draw from a core conviction to expand health coverage and access to services.
Aides and outside advisers said Harris learned key lessons from her experience supporting - and retreating from - Medicare-for-all, such as reckoning with the nation’s complicated health system and the best way to make changes to it.
Her campaign also pointed to policy positions released Sunday in which the vice president pledges to “make affordable health care a right, not a privilege by expanding and strengthening the Affordable Care Act.” Harris is seeking to permanently adopt tax credits introduced by the Biden administration that lower the cost of premiums for health plans sold on the ACA insurance exchanges.
Trump, meanwhile, has repeatedly attacked Harris for her past pledge to abolish private health insurance, and his campaign has criticized her as a “flip-flopper” for retreating from positions she took in the 2020 Democratic primaries.
“She wants everybody to be on government insurance where you wait six months for an operation that you need immediately,” Trump said Tuesday.
Republicans also tout a recent analysis by a pair of conservative policy experts, who project that Harris’s 2019 compromise plan would spawn $44 trillion in additional federal spending if enacted today.
“It really points to her lack of seriousness when it comes to health-care policy,” said Theo Merkel, a senior research fellow at the Paragon Health Institute and the Manhattan Institute, who co-wrote the new analysis with Stephen T. Parente, a finance professor at the University of Minnesota. Both men served as policy officials in the Trump administration.
“The fact that she just willy-nilly embraced such a radical proposal, and then cast it aside the next time around … if she viewed it in her interest, she could absolutely grab something like this again,” Merkel said.
Some Democrats and policy experts countered that Harris’s 2019 plan was a pragmatic solution to a rift that was splitting the Democratic Party.
“I really thought Senator Harris, at the time, had a kind of ingenious way” of expanding health coverage without abolishing private health insurance, said Kathleen Sebelius, who served as secretary of the Department of Health and Human Services during the Obama administration and advised the Harris campaign on its 2019 health plan.
Jacob Hacker, a Yale University professor who in 2001 conceived of a proposal known as the “public option” - the idea to create a government-run health insurance plan that Americans could sign up for, which was central to Harris’s plan - wrote in the New York Times last month that the Democratic presidential candidate should lean in to the vision that her team sketched out five years ago.
“She shouldn’t run away from it. She should embrace it as a central part of her 2024 campaign both because it is smart policy and because it is smart politics,” Hacker wrote.
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A surprise announcement
Harris’s allies say that her Medicare-for-all plan - to paraphrase their candidate - didn’t just fall out of a coconut tree. The 2019 proposal needs to be understood in the context of all that came before it.
First came a memorable town hall in August 2017 - more than 2,500 days ago, and more than 2,500 miles away from Tuesday’s debate stage - where the freshman senator made a promise that would help shape her first presidential campaign.
“I intend to co-sponsor the ‘Medicaid for All’ bill because it’s just the right thing to do,” Harris told a crowd in Oakland, Calif., even as she botched the name of the bill, mixing up two of the government’s major health insurance programs. Medicare is a national program that provides health coverage for older Americans; Medicaid is a joint federal-state program that provides coverage for low-income Americans.
The first-year senator’s announcement - which caught some staff by surprise - made her the first senator to endorse Sanders’s proposal that year.
Politico later deemed Harris’s surprise announcement the most consequential moment of the 2020 Democratic primaries, as it prompted other presidential contenders to hurriedly align themselves with Sanders and Harris and rapidly endorse Medicare-for-all, too, a bill previously viewed as a political long shot. The resulting policy fight consumed the party, as candidates bickered over details, including how quickly their Medicare-for-all plans would be phased into existence.
It also led to some second-guessing by Democrats, as polls across 2019 found that many Americans were worried that shifting to a national government-run health system could delay access to care and cause other disruptions. Harris and her team heard directly from voters who feared the consequences of rapidly upending the nation’s health system.
By summer 2019, Harris’s team was at work on their own proposal, written mainly by her longtime policy adviser Rohini Kosoglu and physician Kavita Patel, said four people with knowledge of those efforts. Meanwhile, Harris policy aide Kelsey Mellette and Harris spokesman Ian Sams provided support and assistance with the plan’s rollout. The campaign also enlisted outside experts such as Sebelius and Topher Spiro, who was vice president for health policy at the left-leaning Center for American Progress, to provide additional analysis or help to validate the plan.
Harris “was not wishy-washy about what she wanted. She was very clear,” said one person who worked on the plan and spoke on the condition of anonymity to discuss a sensitive policy matter. “And it always came back to: ‘I think people should have more affordable choices.’”
Released in July 2019, the resulting plan broke with Harris’s rivals by effectively proposing “Medicare Advantage for All” - an idea that borrowed from an offshoot of Medicare known as Medicare Advantage that allows older Americans to enroll in health plans provided by private health insurers.
Under Harris’s plan, Americans of all ages would have been able to buy into an upgraded version of the traditional Medicare program, with more benefits such as additional mental health services. The plan would be phased in over 10 years, with newborns and uninsured people immediately enrolled. Meanwhile, private insurers could continue selling plans, too, if they met new standards set by Medicare.
Some health policy experts praised the proposal as a more realistic path to universal health coverage than Sanders’s proposal, which would have taken effect in four years and was intended to eliminate the nation’s vast private-health insurance bureaucracy. But Harris’s compromise plan became a political piñata, battered from the left by Sanders supporters who accused her of trying to co-opt his message through an insufficient alternative, and hammered from the right by critics who accused Harris of proposing a plan that would still be politically unworkable.
And for some outside observers and even some aides, Harris’s evolving position on Medicare-for-all - and her televised struggles to explain it - became emblematic of her short-lived presidential campaign. The senator ended her bid in December 2019, weeks before the first primary contest.
Meanwhile, Joe Biden - the only major Democratic candidate not to embrace Medicare-for-all - ended up winning the primaries and the presidency.
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Lessons learned
Aides say that as vice president, Harris gained visibility into the policy process that she lacked as a 2019 presidential candidate, such as better understanding how to enact major legislation, oversee government agencies and pursue other ways to achieve her priorities.
“She certainly learned over the 3½ years here, the importance of incremental progress,” said Kristine Lucius, Harris’s domestic policy adviser in the White House, citing Democrats’ targeted moves to achieve health policy victories, including capping the cost of insulin at $35 a month for older Americans, empowering Medicare to negotiate the price of prescription drugs and helping more people get health insurance through existing programs.
The White House on Tuesday announced record levels of health coverage through the Affordable Care Act.
Keeping with Harris’s focus on building on the current system, her campaign has enlisted Nancy-Ann DeParle and Chris Jennings - longtime health policy experts who helped oversee the implementation of the Affordable Care Act in the Obama White House - among her roster of outside advisers. Patel, who co-authored her 2019 plan, has continued to provide guidance, too.
Hacker, the Yale professor, said he wants Harris to resurrect her 2019 campaign language on the public option but understands why she hasn’t.
“Her health care proposals, and indeed her policy proposals across the board, remain at a high level of generality,” Hacker wrote in an email. “I tend to think that this is a pragmatic stance that reflects, among other things, extreme uncertainty about what the post-election governing environment might look like.”
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