Analysis: The issue of what exactly single-payer means has become a flashpoint in the race for the White House.
WASHINGTON — "Medicare for All"? Or Medicare for all who want it?
Democrats running for president will need to decide which one they're supporting or risk ending up in the muddled situation Sen. Kamala Harris, D-Calif., found herself in last weekend.
Harris made a decision early in the race to run on single-payer Medicare for All, specifically a bill by Sen. Bernie Sanders, I-Vt., that would effectively replace existing private health insurance plans with a souped-up version of Medicare that covers more than the current program and requires no premiums or deductibles.
Asked at by CNN's Jake Tapper at town hall in January whether she really intended to ban people's existing private coverage in favor of this new Medicare plan, Harris didn't flinch.
"The idea is that everyone gets access to medical care, and you don't have to go through the process of going through an insurance company, having them give you approval, going through the paperwork, all of the delay that may require," Harris answered. "Let's eliminate all of that. Let's move on."
On Sunday, speaking to Tapper again, Harris reiterated her support for the Medicare for All bill, but then turned to some more lawyer-like explanations of how she would deal with private insurance:
HARRIS: I support Medicare for All, but I really do need to clear up what happened on that stage.
TAPPER: Yes, OK.
HARRIS: It was in the context of saying, let's get rid of all the bureaucracy. Let's get all of the waste...
TAPPER: Oh, not the insurance companies?
HARRIS: No. That's not what I meant. I know it was interpreted that way. If you watch the tape, I think you'll see that there are obviously many interpretations of what I said. What I meant is, let's get rid of the bureaucracy. As it relates to Medicare...
TAPPER: But the bill gets rid of insurance.
HARRIS: But — no, no, no, no, it does not get rid of insurance. It does not get rid of insurance.
Her answer is technically accurate if you squint at it, but it's also likely to confuse voters who want to know what happens to their health care if the single-payer bill becomes law.
A viewer watching might assume that Harris, by objecting to Tapper's characterization, is saying that their own private insurance plans would not be eliminated under the Medicare for All bill she supports.
That's not the case.
In fact, the bill would outright ban private insurance that provides similar coverage to the new Medicare for All plans after a short transition period. That means everyone with comprehensive employee benefits or a private plan through the Affordable Care Act today would be moved onto Medicare.
Harris said the Sanders bill "doesn't get rid of supplemental insurance," referring to plans that cover other features. She also went on to detail the many benefits voters could expect from their Medicare for All plans, which would include dental and vision.
But the supplemental insurance Harris referred to is very different than what most people associate with private insurance today.
Sanders has said he envisions these remaining plans covering a handful of items like cosmetic surgery that are left out of Medicare. For everything else, the only option is Medicare.
This has been a recurring issue. Harris told Pod Save America last month that "everyone would be in the system" under her plan. But she also shot down a similar question on whether it would eliminate private coverage, saying, "I don't believe we need to get rid of private insurance" before referring to supplemental plans.
Sanders, by contrast, tweeted in March: "You're damn right we're going to get rid of greedy health insurance companies."
There's a broader problem for Democrats: Harris has arguably been one of the most clear and consistent candidates on health care in the field.
At the time Harris endorsed single-payer health care as a presidential contender, it was easy to envision much of the Democratic field doing the same. Several rivals, including Sens. Cory Booker, Kirsten Gillibrand and Elizabeth Warren had also co-sponsored the Sanders bill and continue to do so now. Beto O'Rourke had also praised it during his 2018 run for Senate, but back off eliminating private insurance when he entered the presidential contest, saying he knew that people like their employer-provided coverage.
But since then, the debate about single-payer has changed. Democrats have grown increasingly concerned about Republican attacks on the bill's most controversial feature, the same one Harris was asked about: eliminating existing private plans in favor of the new Medicare plan.
With the exception of Harris, Sanders and Rep. Tulsi Gabbard, candidates who signed onto single-payer bills have mostly stopped short of endorsing them on the campaign trail. Instead, they've emphasized proposals that would maintain a role for existing private plans.
In O'Rourke's case, he said he had changed his mind. Others, like Booker, have argued political obstacles make passing Medicare for All unlikely. Some, like Gillibrand, argue that adding a public option will lead to Medicare for All because people will voluntarily choose it over inferior private insurance options. Warren has said she's looking at multiple approaches.
This ambiguity allows candidates to appeal to voters satisfied with their own insurance without antagonizing voters who like the idea of one single-payer plan. But it can make it tougher for voters to figure out what's actually on offer when candidates talk about Medicare for All, especially as many are learning about these policies for the first time.
A January survey by the Kaiser Family Foundation found 55 percent of voters interpreted the phrase "Medicare for All" to mean a public option they can turn to if they don't like their private plans, rather than a single-payer, government-run program that covers everybody.
There's a case to be made for replacing nearly all private insurance with a new single-payer plan, one that Harris alluded to in her CNN appearance. Advocates argue it would make for a simpler, more cost-effective system that keeps people from falling through the cracks.
But to win that debate, candidates who support the idea have to actually make the argument, and that means explaining in clear terms what happens to people who have private insurance now.