WASHINGTON (AP) — Health care for all. It's a goal that tugs at the heartstrings of Democrats, but pursuing it usually invites political peril.
Now Bernie Sanders and Hillary Clinton are clashing over this core question for liberals, making it a wedge issue in the party's presidential primary.
It's a choice between his conviction that a government-run system would be fairer and more affordable, and her preference for step-by-step change at a time of widespread skepticism about federal power.
The late Sen. Edward Kennedy once championed a Sanders-like "single-payer" system, yet during nearly 47 years in office Kennedy also embraced less sweeping and more politically feasible ideas. Health care realists greeted President Barack Obama's law as vindication. But with 29 million still uninsured and deductibles of over $3,000 for taxpayer-subsidized coverage, some Sanders supporters call it the "Unaffordable Care Act."
Health care for everyone remains the aim for Democrats. The differences are over the best way to get there.
"It's compelling to see the longstanding argument over big, revolutionary change versus more incremental change personified in two candidates, Bernie and Hillary," said John McDonough, an aide to Kennedy during the Obama health overhaul debate.
The worry is about provoking a fatal backlash from the political right.
"Bernie speaks to the hearts of Democrats, and Hillary speaks to the head," added McDonough, now a professor at the Harvard T.H. Chan School of Public Health. "It's about who is more in tune with the actual opportunity and possibility of the time."
Both candidates seem to be struggling to clearly frame the issue.
Sanders sees the destination, but hasn't been able to lay down a roadmap for getting there. Clinton can't seem to fit her menu of tweaks into a persuasive vision. They're talking past each other, said Yale professor Ted Marmor, in a "dialogue of the deaf" that leaves voters confused.
Signed almost six years ago, Obama's health overhaul is the starting point for Democrats who would succeed him. About 16 million people have gained coverage, and the uninsured rate has fallen to 9 percent, a historic achievement. Economic recovery helped, but the biggest increases in coverage came after the health law's insurance markets and Medicaid expansion got going in 2014.
Nonetheless, 28.8 million remain uninsured, and many are still struggling to pay for care even though they have coverage. A government survey estimated that 44.5 million people under age 65 were in families with problems paying medical bills. On top of that, "Obamacare" is mind-numbing to many consumers, a program that combines two of the most complicated areas: insurance and taxes.
"The Affordable Care Act made some improvements for some people, but the health care system is failing lots of Americans," said Steffie Woolhandler, a longtime single-payer activist and primary-care physician. "That made it inevitable that further reform would be back on the table."
Under Sanders' plan there would be no premiums, no deductibles, no copayments, no hospital bills. Instead, there'd be significant tax increases.
Government-run health care in the world's richest country in theory should be able to cover everyone and keep costs manageable, but Sanders has been unable to demonstrate that the math behind his plan adds up. One analysis found he overestimates how much his proposed new taxes would raise; another concluded he underestimates the plan's costs.
Former President Bill Clinton's failed 1990s health plan pledged coverage for all, but it maintained a private insurance market, albeit highly regulated. A key element of Obama's law — the requirement that individuals get health insurance — comes from a Republican counterproposal to the earlier Clinton plan.
Now Hillary Clinton has pledged to build on Obama's progress, outlining policy proposals to limit prescription drug prices and out-of-pocket costs. She'd repeal Obama's unpopular "Cadillac tax" on high-cost health insurance plans, which is meant as a brake on spending.
But Clinton doesn't connect the dots on how her ideas might advance age-old Democratic aspirations.
"I think she has to go back to those basics and stay there," said Rep. Jim McDermott, D-Wash., who once introduced single-payer legislation with Sanders, but is supporting Clinton. He checks off a list: "Coverage for all, no pre-existing conditions, no medical bankruptcy."
Recent analysis from the nonpartisan Kaiser Family Foundation suggests that there's room to cover many more uninsured people under the framework of Obama's law. Nearly 6 in 10 of the uninsured would be eligible for subsidized private insurance, existing Medicaid programs or, if the remaining states accept it, expanded Medicaid.
But incremental progress is unsatisfying for Sanders and those committed to a single-payer plan. If elected president, the Vermont senator says, he'd lead a political revolution for universal health care.
Other Democrats wonder.
"We saw a political revolution around health care reform," McDonough, the former Kennedy aide, said of the "Obamacare" debate. "It was called the tea party."