Where Bernie Sanders' Health Care Crusade Might Go From Here

Bernie Sanders can make a real difference in the causes he’s championed, even if he doesn’t become president.

That’s particularly true for one of his signature issues: health care. No matter what happens with the Democratic presidential nomination, the Vermont senator can keep pushing to to fill in the holes of Obamacare, while creating the building blocks for the single-payer system he has advocated for his entire political career.

Health care has featured heavily in Sanders' campaign. He’d scrap existing insurance arrangements and put in their place a new, universal insurance program that the federal government would administer. It’d be similar to “Medicare for all,” as Sanders likes to say, although the coverage would actually be considerably more generous than what even today’s seniors get. On paper, it would all but eliminate the private health insurance industry.

Versions of single payer exist in countries such as Canada, Taiwan, and the United Kingdom. Others countries, like France, provide insurance through quasi-independent organizations but operate more or less like single-payer systems. Progressives have long dreamed of creating such a system in the U.S., and it’s not hard to see why.

Overseas, single payer systems provide nearly everybody with relatively generous coverage, while allocating less money to health care than the U.S. does. They accomplish this partly by sharply reducing insurance related billing, overhead, and profits, but mostly by dictating to the providers of health care what insurance will cover and at what price.

The supposed weakness of single-payer systems is that they make people wait a long time to see the doctor, but the best available statistics, from the Commonwealth Fund, shows that it all depends on which country you look at -- and whether you focus on primary or specialty care. The U.S. looks better than these systems in some aspects and it looks worse in others.

One area where there's no ambiguity is “mortality amenable to health care,” a metric that scholars designed to measure how a health care system performs, is better in these countries. The U.S. lags behind pretty much every other developed country and it has far more people facing economic hardship or forgoing care because of cost. 

While none of these statistics are perfect, together they make it impossible to argue credibly that the U.S. has a better health care system -- a point Sanders has made many times. But trying to create a single-payer system here would pose titanic political challenges, and not just because private insurance companies would fight as hard as they could to preserve the business of selling health benefits.

Other parts of the healthcare industry, including doctors and hospitals, would fight equally hard because they’d fear, correctly, that a single-payer system would reduce their incomes. People with private insurance from employers, however enthusiastic about single-payer in theory, would quickly get skittish about giving up what they have. Americans with more conservative beliefs would oppose single-payer on principle.

The practical challenges of creating single-payer might be more daunting. Dramatically reducing payments to doctors and hospitals would likely cause many to cut back on what they provide or to go out of business altogether, leading to some combination of economic disruption and shortages of appointments and hospital beds. In order to avoid this, a single-payer plan would almost certainly require either much higher taxes than Sanders had acknowledged or much less generous coverage.

Ever since January, when Sanders published his plan and made clear that he was serious about pushing such an initiative as president, these obstacles to single-payer have been the focus of intense scrutiny from liberal policy analysts and writers. (Some of this scrutiny came from me and provoked sharp but smart retorts from analysts more sympathetic to Sanders.) But these are arguments against attempting to relitigate comprehensive health care reform in 2017. They are not against touting single-payer as an ideal -- or trying to improve upon the Affordable Care Act, so that it starts to look more like some of the successful systems abroad. 

And there's a big need for improvement. The law has reduced the number of Americans without insurance to historic lows, so people are (probably) healthier and (almost certainly) more financially secure. But millions still struggle with medical bills. This includes millions who have insurance, whether through Obamacare or their employers, yet find either the premiums or out-of-pocket costs more than they can handle. 

Meanwhile, the new government-regulated marketplaces through which private insurers compete for business are still fragile. Many insurance companies are losing money, because their new customers are running up higher medical bills than the firms expected. Either they're going to have to raise their premiums or drop out of the marketplaces altogether.

Sanders should be in a position to do something about this next year, even if he is not president. He'd be occupying one of the safest seats in Congress and, for the first time in his career, he would have the visibility and support to seriously influence the congressional agenda. Sanders could use that leverage to promote narrower initiatives that would lay the groundwork for single-payer or at least introduce its most successful elements, so that the U.S. system might more closely resemble that of other countries (like the Netherlands or Switzerland) that rely on heavily regulated private insurance to provide universal coverage.  

Sanders has talked about drug prices repeatedly on the campaign trail. In most other countries, including those with single-payer, the government negotiates directly with the pharmaceutical industry over what to pay for drugs.  Another initiative that he could promote would be some kind of government-run insurance plan into which people could enroll voluntarily. That could mean gradually opening up Medicare to people who are not yet 65 or creating a new public plan that would compete with private insurers in the Affordable Care Act exchanges.

Efforts to include such a “public option” in the Affordable Care Act failed, thanks to staunch political opposition that still exists. But with drug prices in particular, Sanders would be championing a cause that polls show to be wildly popular, even among conservatives voters. And while the Democrats might not have the 60 Senate votes they had in 2009, the caucus as a whole is more liberal, while the party itself is also moving in that direction. It'd still be a tough fight. But if Sanders and his allies could prevail, he'd bring single-payer or something like it a little closer to reality, while improving people's lives in the process.