Illustration: Rebecca Zisser/Axios

As the 2020 campaign ramps up, Democrats may be able to rally their base by talking about universal coverage and making health care a right through Medicare-for-all. Republicans may be able to motivate their core voters by branding progressive Democratic ideas as socialism.

The catch: But it’s the candidates who can connect their plans and messages to voters’ worries about out of pocket costs who will reach beyond the activists in their base. And the candidates aren’t speaking to that much, at least so far.  

By the numbers:

  • The anxiety over out of pocket costs is real. In a January 2017 Kaiser poll, 48 percent of voters worried about paying their health care bills.
  • People who are sick are especially concerned, with 66 percent worried and 49 percent very worried.
  • It isn’t just in their heads: a whopping half of people who are sick have a problem paying their medical bills over the course of a year. The health insurance system is not working for people who are sick.

Thanks in part to the Affordable Care Act, only 10 percent of the population remains uncovered. But that means many Americans are less focused on getting to universal coverage, even though candidate after candidate talks about it. They have insurance and are focused on their own, often crippling health care costs.

  • Most Americans are healthy and don’t use much care, but almost everyone, not just people with a major illness, worries about what might happen if they or a family member get cancer or heart disease or suffer a permanent injury.
  • That's what fuels health care as an issue: the fear of facing costs people know they cannot afford. And that’s why protections for people with pre-existing conditions broke through as a prominent issue in the midterm election.
  • The debate and the Democratic message could shift back to the ACA again, after President Trump and the Justice Department’s surprise decision to push for throwing out the entire law in the courts. That move handed Democrats a political opportunity they will not ignore: a pre-existing conditions debate on steroids.

Recent trends have made problems with out of pocket costs worse:

Some of the administration’s policies are exacerbating the problem, such as their efforts to push cheaper short term insurance plans for the healthy, which drive up costs for the sick because they leave fewer healthy people in the regular insurance plans to help pay for sick people's costs.

  • Several of the candidates' plans address out of pocket costs, including the Bernie Sanders plan, which eliminates them. Their advocates just don’t talk about it much.

The bottom line: It’s hard to see the new debate about the health system breaking out of familiar boxes unless the messaging changes. And when the general election comes, both parties will have to convince voters that they will do something about out of pocket costs if they want to reach beyond core base voters. 

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