Health care will be a central issue in the 2020 election, and Democrats will have to choose to either support expanding the Affordable Care Act or overhauling the health care system with Medicare for All.

Younger voters like those at the University of Georgia will be key to defeating President Donald Trump. According to polling from Gallup, his approval rate is only 28% among adults 18-29 versus 48% for those over 65. Further, Pew Research found that 70% of younger Americans believe government should do more to solve our nation's problems, while only 39% of the Silent Generation felt this way.

And, health care will be a battleground in both the primaries and the general election. There are two distinct Democratic camps regarding health financing reform: a. Medicare for All or b. just expanding the Affordable Care Act.

A bit of history helps us understand the health policy situation. When he was an Illinois State Senator, former President Barack Obama indicated that Medicare for All was the optimum solution. Specifically, Obama was recorded saying, "I happen to be a proponent of a single-payer universal health care program.”

In fact, a single-payer system is clearly superior to what we have now from both access and long-term cost containment viewpoints. According to the Census Bureau, there were 27.5 million people without health care at any point in 2018. In our own state, 13.7% of the population was uninsured in 2018. All of these individuals would have coverage under Medicare for All, as they do in Canada for example.

From a cost containment viewpoint, health care as a percentage of GDP in the USA has gone up from 6.247% in 1970 to 16.937% in 2018, according to OECD data. That means other priorities like education, research, infrastructure and so on are suffering.

Costs can be contained via single payer. For example, Canada’s 2018 per capita cost was $4,974 versus $10,586 here. Per OECD data, many developed nations with universal health coverage pay even less than Canada. None pay more than the U.S.

In 2009, Obama faced a perplexing decision: push single payer or try something else, leaving tens of millions without coverage. Even with Democratic control of Congress and the presidency, getting a single-payer system past Democratic conservatives with financial ties to the insurance lobby like former Sen. Joseph Lieberman — who has since declared himself an independent — would have been nearly impossible.

So, Obama went for second place with the Affordable Care Act instead of going for a gold medal with Medicare for All. He purposefully based Obamacare on the conservative “Act Providing Access to Affordable, Quality, Accountable Health Care”, passed in Massachusetts in 2006 under former Gov. Mitt Romney, thinking that by using private insurance and a Republican expansion model, the GOP would support it.

He was naïve; the GOP was dedicated to voting against Obama, no matter what he presented and then making Obamacare “the” 2010 campaign issue.

Obamacare lost the Democrats their majority, due to an impressive GOP opposition strategy and poor marketing of the ACA concept and implementation by the Democratic party and the government. However, according to Gallup, the ACA has made an amazing comeback. People have realized its considerable benefits, leading to much higher popularity.

The same could happen with Medicare for All if the Democrats win the presidency, the House and the Senate in 2020. The GOP will continue to call Medicare for All “socialism” and claim people with private insurance will lose their physicians and hospitals to “government-controlled health care.” Unless the Democrats can unite and sell single payer they could again lose the House and Senate in 2022.

As with the ACA, the public would come around once these benefits were realized. The Democrats would eventually end up on top, much stronger than they are currently.

But short-term, because of the lack of a coherent health care stand by Democrats, the percentage of Americans supporting health care for all Americans has already dropped to 53% from 60% a year ago, according to Pew Research data. The Democrats must show a united front now on Medicare for All if they want to be successful in 2020.

But, it’s not easy. Democrats still believe in government, with 78% saying it’s the government’s responsibility to cover everyone. However, 34% of the Democrats still believe in a mixed public/private system, as in current Medicare.

The majority of Democrats under 50 do believe in Medicare for All. So do 57% of liberal Democrats, as opposed to just 33% of conservatives or moderate Democrats.

If younger people come out in the primaries, Sen. Bernie Sanders or Sen. Elizabeth Warren who support Medicare for All will prevail. If not, welcome back former Vice President Joe Biden who supports expanding Obamacare for the general. Motivated liberals could win the general election for the Democrats, or stay home, as they did with Hillary Clinton in 2016.

So, that’s the Democrats’ dilemma. Vote for progressive folks who are favored by younger voters and will do the right thing for the long term but might hurt the Democratic Party in the short term. Or, vote for the moderates who might have a better chance of getting elected via swing state wins, but will do little to obtain needed change, hurting the party in the longer term, especially with younger voters.

If Biden wins the nomination, will younger voters then stay home, re-electing Trump? We will just have to wait and see.

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