Politics

The Single-Payer Test

Medicare-for-All isn't just an empty slogan. It's a test of leadership.
April 29, 2019
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Single-payer is not simply a slogan – or even just an ambitious public policy blueprint for transforming the American healthcare system. More than any single issue, it’s a test of leadership which could define whether Democrats are positioned to defeat Donald Trump or whether, besotted by ideological rapture, they will transform a potential winner into an electoral poison pill.

As of now, Trump is bent on healthcare harakiri: supporting a lawsuit aimed at eliminating the Affordable Care Act with nothing waiting to take its place. The only way for Democrats to squander that advantage is by surrendering to Bernie Sanders’ insistence that his way is the only way, allowing the GOP to argue that the consequences of electing a Democrat would be even worse.

The question epitomizes a larger choice: Whether the party will offer a broad vision with optimal appeal, or hobble itself with a laundry list of litmus tests which animate a slice of the electorate even smaller than Trump’s base.

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The totemic issue of healthcare threatens to widen the party’s underlying ideological fissures into an unbridgeable chasm. On one side is Amy Klobuchar, who rejects single-payer in favor of more incremental, but practically achievable, improvements in the healthcare system. On the other stands Sanders, the self-described “democratic socialist” who conjures an intoxicating “political revolution” which will obliterate all obstacles in a tsunami of public support. Between them a brace of Democratic presidential contenders, like cartoon characters, are engaged in a seriocomic effort to keep one foot on each side.

They will get no hand from Bernie: single-payer encapsulates his self-image as the uncompromising truth teller in a party of political mollusks he refuses to formally join. When Nancy Pelosi introduced legislation to strengthen the Affordable Care Act, Democrats from swing-state moderates to ardent progressives—including Alexandria Ocasio-Cortez—signed on. Sanders refused. “The incremental reform that I support,” he proclaimed, “is phasing in ‘Medicare for all’.”

The cataracts on Sanders’ inner vision blind him to the obvious. Polling consistently affirms the popularity of fortifying the ACA, continuing to protect people with pre-existing medical conditions, and lowering prescription drug prices. These “incremental reforms” would immediately benefit millions of Americans who are falling through the cracks in our current healthcare system. Legislation proposed by House Democrats would allow 156 million people to keep their private insurance coverage—with which most profess satisfaction—while allowing others to buy into an enhanced version of Medicare. Short of single-payer, Democrats could try to lower prescription drug prices by importing drugs from Canada, negotiating prices under Medicare, or even, as Elizabeth Warren proposes, allowing the government to manufacture affordable generic drugs where the marketplace fails to provide them.

Why, then, is Sanders unwilling to accept such measures as a down payment on the goal of universal healthcare coverage? Says he: “If I look at polling 70 percent of the people support Medicare for all. . . . I’d be pretty dumb not to develop policies to capture what the American people want.”

Yet again, Sanders misreads reality: while single-payer may sound appealing, most Americans don’t know what it means.

Once people start listening more closely to what single-payer entails, its popularity evanesces. As one example, 58 percent oppose a plan which eliminates private health insurance. As a Democratic senator told me: “Imagine what happens when Trump runs an ad with a steelworker in Pennsylvania complaining that the Democrats are taking away the employer-based healthcare his union fought for.”

Philip Rotner argues, convincingly, that the myriad uncertainties and unintended consequences of “Medicare for All” could turn single-payer into a nightmare of bad politics and failed policy – theology masquerading as the one true path to reform. There is, in fact, no way to predict what its impact on care would be. And while Sanders skimps on the details on how he would finance his proposal— throwing out a panoply of possibilities for taxing wealthy people—its daunting ambitions augur higher taxes on the middle class.

While single-payer advocates argue that these would be offset by eliminating outlays for private insurance and deductibles, the truth is no one really knows if that would be true – or, if so, for whom. Such pivotal uncertainties killed off single-payer plans in two bright blue states—California and Vermont—and in purple Colorado.

A companion irony is that Sanders’ healthcare Hail Mary is unlikely to be enacted even if Democrats win the presidency and both branches of Congress in 2020. Betting the house on a legislative inside straight seems like a misbegotten gamble for a party focused, at the very least, on expelling Donald Trump.

Obviously, Nancy Pelosi disagrees with Sanders—sensibly, she doesn’t care to risk a majority won, in great measure, by moderates running in swing districts. Of single-payer, she says, “Show me how you think you can get there.” Similarly, a number of swing state senators—including Michael Bennet of Colorado, Debbie Stabenow of Michigan, Jeanne Shaheen of New Hampshire, Tim Kaine of Virginia, and Catherine Cortez Masto of Nevada—reject single-payer in favor of expanding coverage by opening a public option.


And yet Sanders is trying to use the gravitational pull of the presidential primary contest to suck the party into his vortex. Kamala Harris and Kirsten Gillibrand have followed Sanders the furthest on his electoral limb—precipitating a stumble by Harris in which she first advocated, then fudged, eliminating private insurance companies. Yet both have also tried hedging their bets by supporting a public option.

Other contenders still straddle the chasm even as they reach for a lifeline. Cory Booker, Pete Buttigieg, and Elizabeth Warren all purport to support some version of single-payer while also embracing a public option. Along with Klobuchar, Booker rejects abolishing private insurance, while Buttigieg and Gillibrand temporize, and Harris and Warren remain studiedly obscure.

This hardly rates a supplement to Profiles in Courage. But the backpedaling is at least useful in identifying Democrats who, with one eye to the general election, are leery of becoming lemmings following Bernie over the cliff.

Aside from Klobuchar—and possibly Joe Biden—only one Democrat has chosen to be forthright: Beto O’Rourke. Here, as elsewhere, he belies complaints that he is light on policy. Eschewing single-payer, he embraces the House Democrats’ proposed legislation. Observes O’Rourke, “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.'” Further, he explains: “If we become too ideological or too prescribed in the solution, we may allow the perfect to become the enemy of the good.”

Precisely. But such is Bernie, forever entranced by the perfection he imagines—encased, like a ship in a bottle, in the cul-de-sac of his own mind.

Sooner or later, his rivals will have to leave him there much more explicitly, taking the path of electoral reason chosen by Nancy Pelosi. They may incur a short-term cost among Sanders’ most ideological supporters. But the 2020 primary fight will be unusually long and grueling, and the general election will be fought on very different grounds—and against an opponent for whom distortions and demagoguery are weapons of choice. It would be worse than feckless to arm a man like Trump with an argument on healthcare which, fortified by substance, could drive voters in crucial states back into his arms.

Democrats need a candidate who forthrightly says that single-payer is not the only—or the best—way to deliver to Americans the healthcare they want. Spoiler alert: It won’t be Klobuchar. Instead, some other aspirant—perhaps O’Rourke, Buttigieg, or even Biden—must show the nerve, leadership, and talent to take on Sanders while giving Democrats, and Americans at large, a program and a vision to believe in. Tempted by the wrong stuff, Democrats need a leader with the right stuff.

So do we all. The stakes, after all, are not just healthcare, but the health of America’s democracy.

Richard North Patterson

Richard North Patterson is a lawyer, political commentator and best-selling novelist. He is a former chairman of Common Cause, a member of the Council on Foreign Relations, and serves on the board of the Renew Democracy Initiative, a bipartisan group dedicated to defending the principles of liberal democracy at home and abroad.