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With the Iowa caucuses less than six weeks away, the Democratic presidential race could be boiling down to a stark Final Four choice for party voters:

Bernie or Liz vs. Joe or Pete.

Two candidates who support Medicare For All and two candidates who oppose it.

Just as abortion became a litmus test for Republicans in past presidential primaries, universal health care has emerged as the defining issue for Democrats now seeking the White House.

Vermont Sen. Bernie Sanders and Massachusetts Sen. Elizabeth Warren have jousted over which of them is the leading proponent of Medicare For All.

When Warren sounds like she invented the notion during the Democratic debates, Sanders interjects his reliable laugh line, “I wrote the damn bill!”

During last week’s debate, Sanders said: “We are the only major country on Earth not to guarantee health care for all people, which is why we need Medicare for all.”

In typically loquacious fashion, former Vice President Joe Biden required several debate performances to hone his opposition to universal health care as simply unaffordable.

“It costs $30 trillion,” he said last week. “Let’s get that straight — $30 trillion over 10 years.”

Biden derided as “absolutely preposterous” the claim that extending Medicare to all Americans would save them money.

“Sixteen percent of the American public is on Medicare, and everybody has a tax taken out of their paycheck now,” he said. “Tell me, you’re going to add 84% more (people) and there’s not going to be higher taxes?”

Pete Buttigieg’s surge in Iowa and New Hampshire has been fueled in part by the South Bend, Ind., mayor’s promotion of a blended system that expands Medicare beyond its current elderly recipients while retaining private insurance as an option for those who prefer their own plans.

As his once longshot campaign took off, Buttigieg faced criticism that he’d flip-flopped on health care by disavowing his clear stance in a February 2018 tweet: “I do favor Medicare for All.”

Now Mayor Pete opposes universal health care as divisive, saying Americans should not be compelled to give up private plans from employers, unions or other sources. Instead he backs what he calls Medicare For All Who Want It.

“We’ve got to break out of the Washington mindset that measures the bigness of an idea by how many trillions of dollars it adds to the budget or the boldness of an idea by how many fellow Americans it can antagonize,” Buttigieg said in the recent debate.

With his brilliant instinct for branding, President Trump is already campaigning against Medicare For All no matter which candidate he ends up facing.

“The radical health care changes being proposed by the far left would strip Americans of their current coverage,” Trump said last week.

The president pulled out the conservative trope “socialized medicine” during an October rally at The Villages, a large retirement home near Orlando in the key swing state of Florida.

Trump signed an executive order originally titled “Protecting Medicare From Socialist Destruction” but later softened to: “Protecting and Improving Medicare for Our Nation’s Seniors.”

As he tries to retain his frontrunner’s position in a race that was once his to lose, Biden plays into conservatives’ hands by rejecting Medicare For All as too expensive.

Biden has criticized Warren’s repeated assertion that her universal care plan can pay for itself, save for a “wealth tax” on the richest Americans.

For all her reputation as a fierce fighter for what she believes in, Warren refuses to acknowledge that her program might require a middle class tax hike. Asked about it by debate moderators, she’s demurred, instead citing benefits such as the elimination of copays and deductibles.

Her contention that Medicare For All can pay for itself recalls President Obama’s infamous 2013 statement: “If you like your health care plan, you can keep it.” So exaggerated was that claim, the nonpartisan PolitiFact chose it as the Lie of the Year — and Obama issued a rare apology.

Before taking too much glee in such Democratic infighting over health care, Trump and his supporters should look back at U.S. election history over the last decade.

With voters naming health care as their most important issue, Democrats swamped Republicans in the 2018 congressional midterms that gave them control of the House.

A decade earlier, Alaska Gov. Sarah Palin’s apocalyptic warnings about “death panels” in then-Democratic presidential candidate Obama’s health-care proposals fed her image as a loose cannon. It was among the extreme statements that led Arizona Sen. John McCain to regret having chosen her as a 2008 vice presidential running mate whose undisciplined campaign contributed to his defeat by Obama.

Win or lose next November, Democrats can take solace in a longer view of history.

In the midst of a Great Depression, FDR was called a communist when he proposed Social Security; now the most hardcore conservative foes of big government do not dare suggest eliminating it.

LBJ was called a communist when he proposed Medicare; today it’s untouchable.

Obama, of course, was called a socialist for pushing his health care expansion; Republican lawmakers have failed to repeal it despite dozens of attempts.

Even if Warren or Sanders should become president, Medicare For All might not happen on their fast-track timetable.

But if the past is any guide at all, our political leaders will end up, sooner or later, matching other industrialized democracies and enacting universal health insurance.

James Rosen is a longtime Washington correspondent who’s covered Congress, the Pentagon and the White House.

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