In Iowa, Beto O'Rourke works to find his footing on health care

DUBUQUE, Iowa — Beto O'Rourke has long advocated for "universal, guaranteed, high-quality health care for all." But how exactly does he think the country should get there?

The question hung over O'Rourke's first few days as a presidential candidate here in this crucial early voting state, where voters and reporters sought more clarity on his approach to arguably the biggest issue in the Democratic primary. It is a race in which many candidates have already embraced some form of Medicare for All, the single-payer health care plan championed by U.S. Sen. Bernie Sanders, I-Vt.

But O'Rourke has a less-than-straightforward history with Medicare for All, and he continued to keep it at arm's length in Iowa, saying at one point that he is "no longer sure that that’s the fastest way” to achieve universal health care. Instead, he arrived in the Hawkeye State ready to talk about a different health care proposal: Medicare for America.

Introduced in December by U.S. Reps. Rosa DeLauro of Connecticut and Jan Schakowsky of Illinois, the legislation would set up a government-run health care program — like Medicare for All — but aims to let people keep their employer-sponsored insurance if they have it and like it.

As he crisscrossed Iowa over the past few days, O'Rourke spoke favorably about Medicare for America when confronted with health care questions, including at a meet and greet Saturday afternoon in Independence. That's where an audience member pressed O'Rourke to be more specific on policy in general and alluded to health care as an example, noting that O'Rourke had said during his unsuccessful bid for the U.S. Senate last year that he would support Sanders' Medicare for All bill if elected.

O'Rourke acknowledged he said that and called the bill a "wonderful way to get to universal health care through a single-payer system." But he then pivoted to Medicare for America — noting that it had emerged after his November loss to Sen. Ted Cruz — and made his case for it.

"It responds to the fact that so many Americans have said, ‘I like my employer-based insurance. I want to keep it. I like the network I’m in. I like the doctor that I see,'" O'Rourke said. "It complements what already exists with the need that we have for millions of Americans who do not have insurance and ensures that each of them can enroll in Medicare. It then suggests additional investments in that program so it becomes the program of choice, and people who have private insurance migrate over to the Medicare system."

O'Rourke added, "Now listen, we may disagree about the best policy path forward, but for me, that affords us the greatest buy-in from the greatest number of Americans because this cannot be the policy or plan of just one person or one party. We’re going to have to get as many people as possible into this if we’re going to achieve that goal."

Throughout his Senate race last year, O'Rourke was generally supportive of single-payer health care but harder to pin down on Medicare for All. He once said in a Facebook post that "a single-payer Medicare-for-all program is the best way to ensure all Americans get the healthcare they need." But he also said he would not sign on to the House's premiere Medicare for All bill, citing concerns that it kept for-profit providers out of the system. He also expressed reservations about Sanders' bill in the Senate, though, as he acknowledged in Independence, he did say he would sign on to the legislation if he made it to the upper chamber.

Under questioning Friday about Medicare for All and his past statements on it, O'Rourke continued to sound less than enthusiastic about it.

“I think that’s one of the ways to ensure that we get to guaranteed, high-quality health care for every single American,” he told reporters in Washington, Iowa. “I’m no longer sure that that’s the fastest way to get there.”

The other Texas Democrat running for president, Julián Castro, has offered a less equivocal stance toward Medicare for All, saying in his announcement speech that "it's time for Medicare for All." On the future of private insurance, Castro has said the country can get to a point where supplemental plans are available to those who want them but that the priority should be ensuring that any American who wants insurance can get it.

O'Rourke's comments in Iowa are unlikely to please many on his left who see Medicare for All as the purest way to get to universal health care. In Independence, his pitch for Medicare for America drew a skeptical retort from the questioner.

"So the greed has to stay in the insurance industry in your opinion?" the man asked.

After a brief pause, O'Rourke replied that he did not see it as a "function of greed."

"I think I have to be respectful to people who just shared with me what I shared with you: They like the program they’re in, they like the insurance that they have," O'Rourke said. "If we become too ideological or too prescribed in the solution, we may allow the perfect to become the enemy of the good. And there are fellow American human lives depending on us finding a solution."