Pete Buttigieg is using Medicare-for-all to draw from Elizabeth Warren’s support in New Hampshire

CONCORD, New Hampshire — Voter Maura Willing, 58, has been a fan of Sen. Elizabeth Warren from “day one.” But she’s still undecided and lately, doubts about Warren’s Medicare-for-all plan have crept into her mind.

“I think that scared a whole bunch of people,” Willing told Vox at a recent house party for one of Warren’s most direct competitors: South Bend, Indiana, Mayor Pete Buttigieg. It’s not that Willing doesn’t like Warren’s detailed Medicare-for-all plan, her public option transition proposal or the tax on billionaires to help pay for it; she’s “99 percent” in Warren’s corner, as she put it. But the missing 1 percent is Willing’s remaining worry that Warren’s health care plan won’t fly with moderate voters in Middle America.

Buttigieg is seizing the opportunity to capitalize on those fears. As his staff and volunteers knock doors in all-important New Hampshire, they’re contrasting their “Medicare For All Who Want It” public option plan with Medicare-for-all — emphasizing the latter would take away private health insurance.

Sen. Elizabeth Warren (D-MA) speaks at a rally to oppose the repeal of the Affordable Care Act and its replacement on Capitol Hill on June 21, 2017.
Astrid Riecken/Getty Images

Touting “choice” is not a new tactic; it’s been used by moderate Democrats and Republicans alike in many a past health care debate, including Obamacare and Bill Clinton’s universal health care plan in the 1990s.

Despite the fact that Sen. Bernie Sanders (VT) “wrote the damn bill” of Medicare-for-all, a Sanders campaign aide in New Hampshire told Vox their impression is Buttigieg’s messaging is largely focused on Warren. The Buttigieg campaign aide pushed back, telling Vox their campaign hasn’t been messaging on any one opponent’s health care plan.

“We’re saying we’re offering you choice, you’re not going to get kicked off your health insurance plan,” the aide said. “A Sanders bill would be the clearest contrast, but we’re not calling people out by name.”

Still, Warren could have more to lose. Recent New Hampshire polls show Sanders supporters are the most loyal of any candidate’s, and there tends to be more crossover between Warren and Buttigieg supporters than for Sanders and Buttigieg. Health care has also proven a vulnerable spot for Warren; after leading in first place this October, her national and early state polling numbers dipped around the time of her health care plan’s release, although they are starting to recover. Buttigieg is currently second place in the Real Clear Politics New Hampshire polling average, behind Sanders; Warren is in fourth place in the state.

The Buttigieg aide said Sanders’s “position is clear, and I think his support is pretty solid. We’re looking for undecideds.”

As Warren is increasingly talking up her public option plan as giving voters “choice,” her campaign has also been having similar conversations with lots of New Hampshire voters, both on the doors and at policy-focused house parties sometimes led by campaign surrogates.

“Health care is a top concern of New Hampshire voters: costs are too high, coverage is too thin, and care is inaccessible for too many,” said Warren’s New Hampshire state director Liz Wester in a statement to Vox, emphasizing Warren’s robust public option and eventual transition to Medicare-for-all. “As President, Elizabeth will fight to make sure no one goes broke because they get sick. … When voters hear this, they’re not just on board, they’re ready to fight to make it a reality.”

Still, some New Hampshire voters remain skeptical about Medicare-for-all — or, rather, they’re not so much skeptical of the plan itself, but of other voters, and how they might feel about it.

Some voters in New Hampshire have Medicare-for-all anxiety. Others say it’s a no-brainer

The debate between Buttigieg and Warren on health care speaks to how big of a flashpoint the issue has become in the 2020 Democratic primary.

Health care is consistently a top issue for Democratic primary voters. It’s a deeply frustrating and personal issue for many; the cost of prescription drugs and care are high, and the costs of many insurance plans keep going up while covering less. But polling also shows a public option — which would give the uninsured or people who don’t like their health care plan the option of a new, theoretically cheaper, plan run by the government — is more popular among Democrats, independents, and Republicans than Medicare-for-all.

“In a general election, a public option will certainly resonate more with swing voters than Medicare-for-all,” said Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation. “Health care is probably the most personal for people, and no one wants to be dictated to about how they get their health care.”

Kaiser Family Foundation polling shows that while American adults narrowly favor Medicare-for-All by 53 percent, a greater majority of 65 percent support a public option. And while Medicare for All and a public option both poll very high among Democrats (77 percent and 88 percent, respectively), the public option garners much more support among independents — 69 percent supported a public option compared to 52 percent who supported Medicare-for-all.

Similarly, few of the 10 New Hampshire voters I spoke to at recent Warren and Buttigieg events believed America is ready for Medicare-for-all, but most were in favor of a public option.

“It’s really hard for people to understand,” said undecided Sunapee voter Susan Fine, 49. “That’s what’s scary about the idea of Medicare-for-all: people don’t know what it’s going to look like. We have to get there in steps.”

The crowd cheers as Sen. Elizabeth Warren speaks after officially filing to be on the ballot for the New Hampshire state primary at the State House in Concord, New Hampshire, on November 13, 2019.
Sarah Rice/Getty Images

Among the list of common fears about Medicare-for-all among these voters: some couldn’t comprehend what a $20.5 trillion plan meant for them individually, and most were convinced it had no chance of passing Congress, even if Democrats manage to win back the US Senate in 2020.

“I think it’s a nice pie-in-the-sky philosophy, but I don’t think we should try to squeeze everyone into a big pot like that,” Concord voter Diane Doner Salice, 68, who is leaning toward Buttigieg, told me.

“It shouldn’t be a great change all at once,” said undecided independent voter Henry Taves, 65, from Peterborough. “People don’t want to give up the insurance plans they have … if you move too quick, you may turn a lot of people off.”

Most New Hampshire voters I interviewed thought a public option was a more “sensible” route. Of course, it’s worth repeating that both Buttigieg and Warren have public option plans, even though Warren has been clear hers is the first step to Medicare-for-all.

Despite having expressed support for Medicare-for-all in 2018 before becoming a presidential candidate, Buttigieg pivoted to a public option early on in the campaign, framing it as a more palatable alternative to single-payer. Warren, on the other hand, has wavered, saying at first that there were many paths to universal coverage, then asserting she was “with Bernie on Medicare-for-all,” before ultimately releasing her two-step plan after sustained attacks from Buttigieg and other moderates over single-payer.

What the various Democratic candidates do share is wanting a much bigger government role in health care, something their voters are largely comfortable with. A few voters didn’t seem bothered with questions of Medicare-for-all’s feasibility or its cost, including Sonya Martina, a 43-year-old voter from Peterborough who told me she and her husband were currently uninsured while they waited for the insurance from his new job to kick in.

“We just cross our fingers,” said Martina, a Sanders supporter who waiting to see Warren speak at a Peterborough bowling alley. She told me she thought Medicare-for-all was a no-brainer.

“I think it should definitely happen. It’s pretty basic,” she said.

And voter Posy Bass, 65, said she believed passing Medicare-for-all and alleviating steep health care costs would help address America’s dramatic income disparity. Bass is supporting Warren, a candidate she called “remarkable.”

“It’s nuts someone is making a decision [whether] to bring their kid with asthma to the ER,” Bass said. “I think it will pay back in spades because our economy is not sustainable. Part of that is having decent services.”

How Warren and Buttigieg’s plans stack up, briefly explained

Both a Warren and Buttigieg administration would start out by pursuing a public option in Congress, but there are key differences between the plans.

The big one is scale. Buttigieg’s main goal is to bolster and improve the current health care system. Warren, on the other hand, is reimagining what health care could look like under an eventual single-payer system (though she specifies Medicare-for-all would be a separate bill and she would not start working on it until the third year of her presidency).

Vox health care expert Dylan Scott has explained both plans in much greater detail, but here’s the quick version.

Buttigieg wants to create an optional government insurance plan into which uninsured Americans would be automatically enrolled. People who get their health insurance through work — about half of the US population — would also have the option to join it. Buttigieg would keep Obamacare marketplaces and expand federal subsidies to help lower the cost of purchasing private insurance on them, and lift the income eligibility cap to allow middle-class families to be eligible for federal assistance. He also wants to fix surprise medical bills and instate an out-of-pocket spending cap for Medicare beneficiaries.

There are still plenty of unknowns about Buttigieg’s bill in terms of cost; the campaign says the plan would be $1.5 trillion and that it would be paid for without adding to the deficit — but they have still not addressed some crucial details. “He has not been specific about what the public option would pay doctors and hospitals,” Levitt said. “That’s a key detail that would determine costs.”

The audience waves signs as Sen. Bernie Sanders introduces the Medicare for All Act of 2017 on September 13, 2017.
Bill Clark/CQ Roll Call

Warren is aiming to pass her plan in the first 100 days. As Scott has explained, it would immediately cover all children under 18 and low-income Americans — every person below 200 percent of the federal poverty level (about $25,000 for an individual, $51,500 for a family of four) with no premiums or cost-sharing.

All of these people could opt in, even if they already had insurance elsewhere. That means it would cover a wider swath of Americans than Buttigieg’s proposed plan. Uninsured people would also be automatically enrolled, with the ability to opt out if they wanted, and Americans who get health insurance through their employers could opt in. Warren would also pass a bill to lower the cost of prescription drugs, and lower the eligibility age for Medicare to 50.

Warren often emphasizes how many forms of health care her plan would cover — mental health, audio, vision, and dental would be included. But lately, she’s also been emphasizing the choice that comes along with a public option; people on private insurance could make the switch if they wanted to, but it wouldn’t be mandated. She’s making a bet a robust public option would be a trial run for Medicare-for-all, and that it will help make the public case for single-payer.

“For people under 18 it will be free, for a family of four making less than $50,000 it will be free,” Warren told me at a recent press conference. “But they will have the option, if that’s what they want to do. And then we will have tens of millions of people across this country who will have the experience of what it’s like to have health care that’s between you and your doctor … without some insurance company standing in between.”

Warren, for one, seems convinced that once these tens of millions of people have had that experience, they’ll be ready to transition to a fully government-run Medicare-for-all plan. In the meantime, she’s trying not to scare wary voters.

Buttigieg is emphasizing “choice.” That’s not a new tactic.

If you go to a Buttigieg event, expect to hear a lot about the need to preserve “choice” and “freedom” around health care.

“You’re not free if you don’t have health care, but we also respect your freedom to decide whether you want it,” he told a crowd at New England College in Henniker, New Hampshire, recently. “Because one way or the other, you should be able to get coverage, but I’m not going to dictate the terms of that coverage.”

Buttigieg tells crowds his goal is to get to universal health coverage, but not through Medicare-for-all. Choice is the key word, and it’s a strategic one.

“There’s a long history of using choice as a wedge to argue against health care reform plans,” Levitt told me. “The emphasis on choice spotlights the big vulnerabilities of Medicare-for-all, which is people wouldn’t be able to choose their insurance and give up their private coverage. In some ways, Buttigieg is previewing some of the arguments against Medicare-for-all that President Trump and Republicans would use in the general election.”

Buttigieg’s campaign believes their polling bump in New Hampshire has been a product of months of messaging around health care, following some notable fall debate performances where he went after Warren on health care.

“That word has been effective. … Our volunteers have latched onto that as talking about Pete’s plan,” a Buttigieg campaign aide told Vox. “It’s an argument Pete made at the debate, but it was supplemented. It was something we started talking about more, our organizers were talking about that. We reached out, texted, called, emailed 16,000 people.”

Some say this focus on choice is scaring voters into believing they might not be able to keep their doctors, and into accepting a costly insurance system.

“The insurance industry use that term a lot to baffle us,” said Wendell Potter, a former Cigna executive turned Medicare-for-all advocate. “It’s conflating the choice we really need and want, and that’s the choice of health care providers.”

Warren has been getting a lot of questions about her health care plan and embrace of Medicare-for-all on the campaign trail over the past few weeks. The fact that Warren has started using the term choice more could mean she recognizes that many Americans still aren’t quite there yet on Medicare-for-all — or that she’s feeling the pressure from Buttigieg.

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