The following is a lightly edited adaptation of What Next, the new daily news podcast from Slate. Listen to What Next via Apple Podcasts, Spotify, TuneIn, Stitcher, Overcast, Google Play, or iHeart.
Republicans have tried to repeal the Affordable Care Act dozens of times over the past several years. But after a dramatic showdown on the floor of the Senate, with then-Sen. John McCain battling brain cancer and flying in to block the bill, there was a shift. For the first time ever, more than half of Americans reported that they approved of Obamacare. And those approval levels have actually stayed pretty high.
And now here we are again, about to go to the polls, and the conversation we’re having about health care is starting to sound different—in Washington and on the campaign trail. But instead of “repeal and replace,” there’s a new catchphrase: “Medicare for all.”
“In 2016, there were 60 people who signed on to the Medicare for all bill in Congress, and then the next version, which is [from] the current Congress, has 120 people signed on,” says Shefali Luthra, a correspondent for Kaiser Health News. “And you also have the growth of the Medicare for All PAC, the Medicare for All Caucus. There’s a lot more interest in, at the very least, signaling that you are part of this group. Being part of this group doesn’t mean that you necessarily support the idea of the legislation, it just means that you want to be in the club.”
But what does it mean to be in the club? When candidates talk about health care on the campaign trail this year, what are they talking about? At least one race shows the perils and the promise of campaigning on health care, a topic that is easily misunderstood.
This week in Tampa, Florida, Democratic gubernatorial candidate Andrew Gillum and his Republican opponent Ron DeSantis met for their first debate. It didn’t take long for these two men to talk health care. Andrew Gillum has been campaigning hard on this issue of Medicare for all since the summer, and he’s not afraid to get personal.
“I grew up having to wait for the free dental plan to come through my neighborhood in order for us to get our teeth cleaned,” he said during the debate.
DeSantis on the other hand is known as a politician loyal to President Donald Trump—a campaign ad features him building a wall with his toddler daughter and reading The Art of the Deal to his infant son. As DeSantis is running on the coattails of Trump, across the aisle, Gillum is pulling a page from Sen. Bernie Sanders.
“Bernie Sanders really popularized the Medicare for all idea a couple years ago,” says Politico’s Dan Diamond. “I went to a Bernie rally a few months ago where Sanders was saying, essentially, Look what we did. This was seen as a fringe idea not so long ago, and now Democrats around the country, and Andrew Gillum would be one of them, are campaigning on this as a reality if they should win election.”
But careful watchers of Sunday night’s debate know that, below the surface, Gillum’s opinion is actually shifting.
“Gillum and some other Democrats who are running for office around the country have moved away from campaigning just on Medicare for all, and they’ve been seizing on saying Medicaid expansion instead,” Diamond says. “And in Florida there are tangible reasons to get voters fired up about Medicaid. One, it’s a tangible program—there have been campaigns over the past number of years to expand Medicaid. And around the nation more Americans have gotten covered by Medicaid since the ACA.”
On the whole, Diamond says that Gillum is trying to push Florida in the direction of more than 30 other states that have already expanded Medicaid.
“It hasn’t happened yet in Florida, because of the Republican control, not just of the governorship but also in the state Legislature,” he says. “While there have been efforts that walked right up to the precipice, they haven’t been able to go over. Partly out of fear that the Republicans have spread, that Medicaid will end up being too expensive, [and] partly because of donor pressure. There are groups backed by say, the Koch brothers, who have been very opposed to any expansion of Medicaid. Because once that expansion is locked in, it is that much harder to roll it back.”
Gillum’s evolution on this issue isn’t just about Florida, though. It can tell us something broader about the state of the Democratic Party.
“Medicare for all is really catchy,” says Diamond. “There’s a reason why Democrats are running on it around the country, [and] it seems like the kind of idea that should be simple: just expand Medicare, which America’s seniors are covered by, just expand that to everybody. The problem with Medicare for all is it’s not clear what it means, or how it would work, or what that would mean for all of us who get covered by employer insurance, or even for our grandparents who are enrolled on Medicare right now. And Republicans have been able to really needle in on that and use that uncertainty against the Medicare for all idea.”
While Gillum supports Medicare for all, Diamond says that a more straightforward path may be to pursue a Medicaid expansion in Florida.
“Medicare for all, that might not be real for years and years to come. And I’ve talked to Democrats and Republicans who have said, for all of the campaign rhetoric, the reality is still very far away,” Diamond adds.
One reason that a Medicaid expansion would be more feasible? Money. As it stands now, most Democrats don’t know how they would pay for Medicare for all, Diamond argues.
“There’s been talk of taxing wealthy individuals, or shifting how the health care system works and finding new efficiencies,” he says. “But I’ve talked to budget wonks—people who believe in coverage expansions, people who in their bones want this idea—and they say the math just doesn’t add up.”
Peter Orszag, who directed the Office of Budget and Management during the Obama administration, is one such person. He told Diamond that he is “deeply skeptical” that Medicare for all could work.
“Orszag compared this to Republicans saying, ‘We will repeal and replace the ACA,’ but not actually having a plan to do it. Democrats are campaigning aggressively, [saying,] ‘We’re going to expand coverage, we’re going to have Medicare for all.’ But none of their plans are so thought out that a lawmaker could take power and then immediately put them in place,” Diamond says.
But the political winds on health care may be shifting again, and the 2018 midterm election in Florida may be the ideal test case.
“If Gillum wins, and if Democrats in the state Legislature make significant gains, as they probably would because Democrats all around the country are expected to make gains, Republicans may be spouting a different tune early next year, and responding to the will of the voters,” Diamond says. “Would the Medicaid expansion in Florida look like the full expansion that perhaps Democrats want? Not necessarily. Could they get to a compromise? Certainly possible.”