WASHINGTON – Senator Elizabeth Warren spoke at length this week about her vision of improving the American health care system, including strengthening the Affordable Care Act and making prescription drugs more affordable. Twice, however, she ignored a question put to her: Would she support the elimination of private health insurance for a single payer system?

"Her goal is to get affordable health care for all Americans," Warren said at Bloomberg Television. There are "different ways to achieve this goal".

In other words: I will not fall into this political trap.

Ms. Warren from Massachusetts and three other Liberal presidential candidates back a Medicare for All bill, which would create a single-payer health plan managed by the government and increase federal spending by at least $ 2.5 trillion per year, according to several estimates. But Warren's determination to bypass an essential but deeply controversial issue at the heart of the single payer model – would people lose the choices offered by private insurance? – illustrates one of the most thorny dilemmas for many Democrats as the 2020 primary begins.

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Their militant base, inspired by Senator Bernie Sanders of Vermont, believes that the party should shamelessly pursue the search for universal health care, by completely ending private insurance. Polls, however, indicate that the electorate in general, particularly middle and upper income voters who propelled the party's substantial gains in the mid-term suburbs, is worried about this "Medicare for" approach. all "in which many would lose their current insurance options and pay more. the taxes.

Senator Kamala Harris of California launched the Republicans' immediate attacks this week by tackling the problem Mrs. Warren had ducked. At a public forum organized by CNN, Ms. Harris quickly acknowledged that she would "eliminate all this," evoking the end of private insurance in a country where nearly 60% of the population enjoys of coverage provided by an employer.

His remark triggered an internal debate on an issue that was essentially theoretical: a decade after the Democrats pushed for the largest expansion of health care since Big Society, they had to gradually rely on the affordable care law or completely eliminate the insurance sector and create a public European-style program?

Four Democratic Democrats – Ms. Harris, Ms. Warren, Senator Kirsten Gillibrand of New York and Senator Cory Booker of New Jersey – are co-sponsors of Mr. Sanders' Bill for Medicare for All, which would replace the affordable care. a single government health plan for all Americans. Medicare is the federal program providing health coverage to people aged 65 and over.

The concept of health insurance for all has become popular among Democrats: 81% support it, according to a recent Kaiser poll. However, voters' opposition to giving up the insurance they were accustomed to provoked negative reactions following President Barack Obama's repeated promise that "if you like your plan, you can keep it" after that. this has proven to be wrong for several million people under its health law. Many Democrats are fully aware of this brutal reaction and the 2020 presidential race will be the first where many of the party's leading candidates will have to explain and defend the meaning of Medicare for all.

For the moment, as Ms. Warren has shown, many candidates do not want to go public with the details. After Ms Harris's comment, her assistants hastened to add that she would also support less radical changes in health care; like most other candidates, Ms. Harris declined an interview request. And on Friday, Mr Booker, a few hours after announcing his candidacy for the presidency, tried to solve the problem by proposing an energetic "no" when he was asked for it when he backed the president. elimination of private coverage.

Still, a potential candidate for 2020 is excited to discuss Medicare for all.

In an interview, Mr. Sanders did not mince words: the system he was considering in the private insurance sector would be: "Cosmetic surgery, you want your nose repaired".

"Each candidate will make his own decisions," said Sanders, "but if I look at the polls and 70% of people support Medicare for all, if a very large percentage of people think that the rich, the very rich, should start paying their fair share of taxes, I think I would be foolish enough not to develop policies that reflect what the Americans want. "

But Michael R. Bloomberg, former mayor of New York City, who is considering a bid for 2020 on a centrist democratic platform, said it would be foolish to even consider a single payer system. "Replacing the entire private system where companies providing health care to their employees would bankrupt us for a very long time," Bloomberg told reporters Tuesday in New Hampshire.

The Congressional Budget Office did not evaluate Sanders' Medicare for All bill, but a study conducted last year by the George Mason University Mercatus Center predicted that federal spending would increase by $ 32.6 trillion in the first decade. According to the study, the cost could be even higher if the bill overestimated projected savings over administrative costs and drug costs, as well as payments to health care providers.

The gap between Sanders, a Democratic Socialist, and Bloomberg, a Republican who has become independent and has become a Democrat, reflects the chasm that reigns in a party that was reorganized by President Trump.

The extremist nationalism of the president simultaneously pushed the left-wing Democrats, urging them to pursue an unequivocal Liberal policy, and attracted the moderate independents and Republicans to the party because they can not stand his incendiary conduct and race demagoguery. These dueling forces have created a growing but thankless coalition that scorns Mr. Trump but is less unified on policy issues such as health care.

And these divisions extend to what is politically the wisest.

Liberals argue that the only way to increase the turnout rate of unlikely voters or win back some of the voters unhappy with Hillary Clinton's corporate interests is to pursue a bold agenda and broaden issues such as health insurance for all.

"Those who have progressive changes are not the ones who will excite people and get them to come forward," said Washington representative Pramila Jayapal, co-chair of the Congressional Progressive Caucus.

And by preserving their options, Democrats risk alienating Liberal primary voters, some of whom view Medicare support for all as a litmus test.

"The center is no longer a good place to follow these policies," said Mary O'Connor, 61, a substitute teacher and horse breeder in Middleburg, Va., Who wants a one-time pay system. "I will be watching very closely, and I will probably join me and volunteer for whoever will be the most powerful for that."

But moderates believe most Democrat primary voters are more determined to defeat Trump than to enforce decisive tests – and ending employer-sponsored insurance would only scare election voters who are eager to chase Mr. Trump but do not want to redo the entire health system of the country.

"Most freshmen who helped get the House back were elected:" We will protect your health insurance even if you are suffering from a pre-existing illness ", and not" We will take all this system and the throwing out the window, "said Kenneth Baer, ​​a Democratic strategist.

Surveys show that Medicare for all – a buzzword that has recently been applied to everything from single-payer health care to programs that would allow anyone to buy Medicare or Medicaid – enjoys broad public support , attitudes varying considerably not only the details, but also the age and income of the respondents.

On the House side, a bill similar to that of Mr. Sanders is being reviewed and will soon be re-introduced with Ms. Jayapal as the lead sponsor. Other Democrats have introduced cheaper billing bills, which would preserve the current system, but would give some Americans under 65 the option of paying for Medicare or a new plan "D & # 39; "Public option". Another bill would give each state the opportunity to let residents buy Medicaid, the government's health program for the poor American.

Buying programs would typically cover 60% to 80% of people's medical costs and would require far less federal spending because registrants would still be paying premiums and not everyone would qualify. Some supporters, like Sen. Jeff Merkley, Democrat of Oregon, described them as a stepping stone towards the establishment of a single full payer system. some of the Democrats running for president co-sponsor these "Medicare for more" bills and those of Mr. Sanders.

Sanders suggested options for raising funds for his plan, including a new payroll tax of 7.5 percent and a wealth tax of 0.1 percent of the highest paid. He also predicted a multi-trillion-dollar economy over the next 10 years through the elimination of the tax exemption that employers receive on the price they pay for employee insurance premiums and other tax breaks.

But Robert Blendon, a Harvard health policy professor who studies public opinion, said it would be wise not to go into the details of the funding at this time.

"The reasons for his failure in Vermont and Colorado were taxes," said Professor Blendon, referring to recent efforts to move to an almost universal health care system in these states, which collapsed unceremoniously because they would have required significant tax increases. "But the primary Democratic voters will not get to the bottom of things to know how these plans will work. What they are going to say is: "Show me that you have the principle that health care is a human right."

The general election will have a different story, added Professor Blendon. If Mrs. Harris were to become the Democratic candidate and continue to embrace the idea of ​​ending private coverage, he said, "she's going to have huge problems."

The challenge for Democrats, said Ezekiel Emanuel, a former health advisor to President Obama, is that many voters see the health system the same way they view politics. "They say Congress is terrible but I like my congressman," as Mr. Emanuel said.

According to the Gallup poll, 70% of Americans with private insurance believe their coverage is "excellent" or "good"; 85% say the same thing about the medical care they receive. The Kaiser poll found that the percentage of Americans who join a national health care plan drops by 19 percentage points when told they would eliminate insurance companies or force Americans to pay more taxes .

Of those earning more than $ 90,000 a year – the kind of voters in House ridings that many Democrats captured mid-term – respondents in the Kaiser poll were particularly suspicious of a system made up of all governments: 64% of them oppose a health insurance scheme for all plans that ended private insurance

"My constituents are fed up with complex debates over complex issues," said Texas representative Lizzie Pannill Fletcher, a rookie from a wealthy Houston district. "We do not want ideologues in charge."

In Vermont, where former Gov. Peter Shumlin abandoned his ambitious single-payer scheme in 2014 after conceding that it would require "huge" new taxes, health care advocates Universals are now resigned to a more progressive approach.

Dr. Deb Richter, a primary health care physician who helped lead the single-payer state movement, said that although the Democratic realm will have to face the word "T", being frank in Regarding the required tax increases, she now thinks a government-run system is a better approach.

"There are ways to do this that do not necessarily have to happen all at the same time," she said, noting that Vermont wanted to start with universal government coverage for primary care only. "But you have to talk about the ultimate goal: we are aiming for Medicare for all, and that's one way to do it."