House Democrats’ first formal foray into debating a national “Medicare for All” system, with a rare initial hearing in the Rules Committee on Tuesday, demonstrates how carefully the party is trying to present a united image on a divisive election-year issue.

Like the broader party, the committee’s Democrats are split over a bill that would shift most Americans into a government-paid health care system. Five of the nine Democrats on the panel, commonly referred to as the “Speaker’s committee,” have endorsed the bill, while four have not.

Given those differences, the party may not rally around a position on how to expand coverage until it selects a presidential nominee. White House hopefuls are debating whether to embrace a single-payer system or build on the current health care infrastructure.

Democrats on both sides hope to frame health care as a right and high costs as an issue to address. Supporters billed Tuesday’s hearing as historic, although it largely lacked fireworks and the loud fights that can break out when lawmakers debate the 2010 health care law.

Instead, the discussion was fairly wonky in a way the presidential campaign hasn’t yet become. Lawmakers weighed the trade-offs between how a single-payer system would affect Medicare payment rates and the costs of implementing such a system.

Flashback: What if we switch to a single-payer health care system?

‘Smartest hearing’

Pennsylvania Democrat Mary Gay Scanlon, who has not signed on to the bill, demonstrated the concerns that more moderate Democrats face. Scanlon said she is committed to moving toward universal health care but isn’t yet sure of the best way to get there.

“I have no question that health care is a human right and that no family should have to go bankrupt or worry about putting food on the table due to medical costs — or have to create a GoFundMe page,” she said. “I’ve already supported measures that would try to lower prescription drug costs [and] allowing Americans over 50 to buy into a public option but I’m trying to parse the best way forward from here, to protect the Affordable Care Act and move to whatever our next step is.”

The understated tone was noticed by members. Rep. Donna E. Shalala, a former Health and Human Services secretary, told CQ Roll Call that it was the “smartest hearing I’ve ever been in.”

“It’s thoughtful. People aren’t grandstanding,” the Florida Democrat said.

The most emotional moments came when one witness, ALS patient Ady Barkan, offered moving testimony, speaking with a synthetic voice since his diaphragm and tongue have been so weakened by the disease. Barkan told the panel his family pays $9,000 each month for the nearly 24-hour home care he needs, rather than moving him into a nursing home away from his wife and son.

A single-payer advocate, Barkan said Medicare for All would deliver high-quality care for Americans and save people money by eliminating premiums, co-pays and deductibles. During the hearing, he told the ranking Republican, Tom Cole of Oklahoma, that he and other patients “needed Medicare for All to be in effect yesterday.”

“My time to deliver this testimony is running out. And, in a much more profound sense, my time to deliver this message to the American people is running out as well,” he said. “Our time on this earth is the most precious resource we have. A Medicare for All system will save all of us tremendous time.”

House Rules Chairman Jim McGovern of Massachusetts, a co-sponsor of the bill, acknowledged it is not expected to pass soon, a fact that Senate Majority Leader Mitch McConnell of Kentucky underscored by criticizing it on the Senate floor that morning.

“I know we won’t pass this bill overnight, but we won’t pass it unless we start the dialogue,” McGovern said.

Trade-offs

Overall, the hearing featured a thorough back-and-forth on the trade-offs that would come with implementing a single-payer health care system. While people would pay more in taxes, they would not pay for health care costs like premiums, deductibles and copays that people currently face.

Those types of trade-offs are part of the key questions that lawmakers would have to answer if they plan in earnest to transition to a single-payer system.

Lawmakers also discussed the at least $32 trillion, 10-year price tag associated with a single-payer system that would shift current health care spending to the government, rather than coverage through private insurance or other programs.

“Medicare for All is affordable,” said Dean Baker, a senior economist at the Center for Economic and Policy Research. “The bulk of the payments should be coming from shifting employer premiums basically to taxes, so it’s not additional money out of workers’ pockets.”

Charles Blahous, a senior research strategist at the conservative Mercatus Center, said he largely agreed with that assessment about cost-shifting.

The Rules panel also discussed the thorny question of how to pay doctors and other providers under a single-payer system. Currently, providers earn most of their revenue from reimbursements from private insurers, while Medicare and Medicaid reimburse them at lower rates. Republicans and single-payer skeptics raised concerns lower payments could close rural hospitals.

Sara Collins, a vice president at the nonprofit Commonwealth Fund, said the amount providers are paid now is driving up health care costs. Lowering provider payments is one way a Medicare for All system would put downward pressure on health care costs.

“One of the major contributions of the Medicare for All bills is the issue out there of how much we’re paying providers right now,” she said. “It’s why we do see some savings in some of the estimates we’ve seen of the Medicare for All bills. It’s a conversation that the country needs to have right now.”

Next steps

The hearing was one of at least two expected in the House this year, with the House Budget Committee expected to hold its own meeting next month.

That would follow a report expected to be released Wednesday outlining the key design components and considerations of a single-payer system, which will likely shape that panel’s hearing.

“We want to make sure that we know all the questions to answer before we go into the hearing, so that’s what that report’s supposed to be doing,” Budget Chairman John Yarmuth of Kentucky said.

At the same time, Democrats are also planning to pass legislation to bolster the 2010 health care law, a move that single-payer advocates say they support.

Rep. Ed Perlmutter said he supported several ideas — including the single-payer bill, beefing up the 2010 law and allowing people age 50 and older to buy into the Medicare system.

“All are improvements over where we are today,” the Colorado Democrat said.

Republicans seemed more than open to discussing a single-payer health care system, in part to highlight what they see as its challenges and the Democrats’ divisions. Republican Rules Committee members said Tuesday they hoped the traditional panels of jurisdiction on health care, the Ways and Means and the Energy and Commerce committees, would hold hearings.

Their GOP colleagues on Ways and Means wrote a letter to Chairman Richard E. Neal asking for a hearing on the issue.

Indeed, the Massachusetts Democrat said Tuesday he would like to hold such a hearing later this year.