海角大神

Olivia Sheldon is one of those voters who鈥檚 still deciding who to vote for in a hotly contested Senate race. But she knows one issue she cares about a lot: health insurance.

鈥淗ealth care definitely needs some work,鈥� she says. 鈥淚 would love to have some reform.鈥�

Ms. Sheldon is an expectant mother who, at age 24, has a job in retail and is studying for a degree in psychology. And for this resident of the mountain town of Harpers Ferry, what鈥檚 needed doesn鈥檛 fit neatly on either side of a debate that typically pits ideals of government-provided care against reliance on free-market principles.

鈥淚 want the government support,鈥� she says, citing the high costs of medical care. 鈥淏ut I want [government] out of the doctor鈥檚 office when I鈥檓 in for an appointment.鈥�

Her views point toward an important reality of the 2018 election: No single issue looms larger on the campaign trail than health care 鈥嬧�� the subject of nearly half of all campaign ads for federal races. Voters want both low prices and high-quality care, and they show support for a strong government role on health policy, up to a point.

In this campaign cycle, one core tenet of Obamacare has moved front and center: that people shouldn鈥檛 face higher insurance prices because of preexisting conditions. Americans widely support that idea, and Democratic candidates have put Republicans on the defensive over the issue in key races such as the one here in West Virginia.

Yet even as a majority of voters say they trust Democrats more than Republicans on health care 鈥� and as proposals of 鈥淢edicare for all鈥� gain a following in some quarters 鈥� policy experts don鈥檛 see an easy path toward meeting voter aspirations.

鈥淭here is not a magic bullet on health care, ... 聽regardless of what the political parties say,鈥� says Chris Sloan, a director at Avalere Health, a Washington-based consulting firm. Referring to the Medicare-for-all idea, he adds: 鈥淚t's not easy to create a single-payer system in the United States that saves a lot of money.鈥�

What the parties are offering

The two major parties offer starkly different visions on health care.

Republicans focus on ever-rising costs and the risk to both individual pocketbooks and federal deficits. Their preferred solutions emphasize longstanding conservative ideals of consumer choice, competition, and flexibility for state-level innovation on policy.聽The Trump administration has moved to make slimmed-down insurance plans available to Americans who don鈥檛 feel they can afford Obamacare.

But that, coupled with other moves, has left them vulnerable to attack 鈥� with GOP candidates scrambling to insist that they, too, support protecting people with preexisting conditions. At least in their rhetoric, the 2018 race has made it a principle both parties agree on, backed solidly by public opinion.

鈥淗ardworking West Virginia families are hurting,鈥� GOP Senate candidate Patrick Morrisey says in an interview on the campaign trail, noting 鈥渟kyrocketing premiums.鈥� He pledges to repeal President Barack Obama鈥檚 Affordable Care Act (ACA) 鈥� but then adds in the next breath, 鈥渨e also need to protect people with preexisting conditions.鈥�

Here in West Virginia, a state that Trump won by a wide margin in 2016, state Attorney General Morrisey is challenging incumbent Democratic Sen. Joe Manchin in a close race, though most polls have shown Senator Manchin leading.

Manchin, a former West Virginia governor who has long positioned himself as a centrist, symbolizes how Obamacare is no longer the liability for Democratic candidates that it鈥檚 been in past election cycles.

In one TV ad Manchin charges that a Morrisey-backed lawsuit against the ACA seeks 鈥渢o take away health care from people with preexisting conditions.鈥� The ad is tailor-made for this conservative-tilting state, as Manchin destroys聽a document representing the lawsuit 鈥� and sends an I鈥檓-not-liberal signal by using a shotgun to do it.

Most Democratic candidates aren鈥檛 toting guns in their ads, but the health care emphasis here in the Mountain State has been echoed in other close congressional races across the nation.聽

For most Democrats, the core ideal for health care policy is universal coverage 鈥� something Obamacare aspired to but didn鈥檛 achieve. As a next step, Democrats in solid-blue districts or states are pitching 鈥淢edicare for all.鈥� But, as appealing as the idea of government-funded health insurance sounds to many Americans, many also question how to pay for it.

Questions in West Virginia

The skepticism is evident in Inwood, a small town in Northeastern West Virginia where Morrisey recently held a rally.

鈥淚 don鈥檛 think that鈥檚 realistic鈥�. Where do you get the money,鈥� says rally attendee D.J. Beard, referring to a single-payer (government) system. A resident of nearby Glengary, Mr. Beard says he鈥檚 registered as an independent and sees a role for government. He himself is on Medicaid and out of work due to a health challenge.

But he thinks Republicans 鈥渁re looking out for the people鈥� while, from what he鈥檚 heard from European acquaintances, single-payer is not a model for the US to aspire to.

His view hints at why Americans have given mixed responses when asked in polls if they鈥檇 support switching outright to a single-payer system. By contrast, polls have found majority public support for the idea of a public health-plan offered alongside other options. A CBS News poll this month found 65 percent of Americans in favor of that idea.

And a Pew Research Center poll last year found 60 percent support for the idea that it is government鈥檚 responsibility to ensure health care for all, up from 47 percent who felt that way in 2014.

鈥淭hose on the right just celebrate everything that Trump says,鈥� says Scott Flanders, chief executive officer of eHealth, an online marketplace for insurance plans. 鈥淭hose on the left want to brand anything that isn't the ACA as bad.鈥�

He says the reality is more complex 鈥� that millions of Americans can鈥檛 afford Obamacare plans, that many are seeing premiums and deductibles soar even when they have insurance through their employer, and that 鈥淢edicare itself is headed toward an unsustainable path.鈥澛�

Still, for now Democrats appear to have momentum on the issue. They have fodder for saying Republicans have sought to undercut the ACA鈥檚 protections. The lawsuit Morrisey backed, along with officials from other states, seeks to overturn the whole law (including its guarantees that premiums won鈥檛 hinge on one鈥檚 medical condition) as unconstitutional.

In other races, GOP lawmakers are under attack for supporting legislation undercutting the ACA. Where Republicans say they鈥檙e still seeking to protect people with preexisting conditions, while promoting greater choice in insurance markets, Democrats say those safeguards are far from ironclad.

Meanwhile, more from Washington

The partisan battle over health policy has been ramping up in recent days.

The Trump administration has sketched a new plan aiming to tame prescription-drug costs within Medicare by linking prices to what鈥檚 paid in other advanced nations.

The administration also announced a move to let states get waivers from Obamacare, potentially opening the door to states using federal dollars to subsidize insurance plans that are cheaper, but which offer less coverage than ACA-compliant plans.

Already, another Trump move is expanding short-term health plans as a cheaper alternative to Obamacare. Critics call it 鈥渏unk insurance鈥� since the coverage isn鈥檛 complete. Mr. Flanders of eHealth argues the plans are a 鈥渃onstructive鈥� adjunct to Obamacare, helping many of some 28 million uninsured Americans to afford some coverage rather than none.

Many Democrats meanwhile say that Medicare for all, paid for with cost controls coupled with some tax hikes, can offer solid insurance to every American.

It鈥檚 possible that a single-payer system could help the US cover more people at a lower overall cost, says Mr. Sloan, the policy expert at Avalare, but he adds, 鈥渋t鈥檚 hard.鈥�

鈥淭o do that, the United States would have to cut a lot of health care spending,鈥� he says. And that could mean reductions in everything from drug prices to physician reimbursements to other areas where the US spends more than other nations. 鈥淭here's a lot of stakeholders [and entrenched interests] in place that that would affect.鈥�