The Coming Democratic Infighting Over Single-Payer Health Care

This article originally appeared at The American Prospect. Subscribe here.

Beware Democrats: There's a new litmus test on the way that you'll have to satisfy if you want to avoid being branded an establishment sellout. It concerns single-payer health care, and while this one can get silly in some quarters, there are serious questions that everyone on the left, from the most moderate Democrat to the most committed leftist, will have to answer.

With the Republicans proving that a health plan embodying conservative principles can garner the support of as much as 16 percent of the American public, there has never been a better time for liberals to make the case for an expansion of government's role in health care. No long ago, single-payer was either something supported by fringe figures, or an idea that Democrats would say they would favor if we were starting from scratch, but that the transition from where the system is now to a single-payer system would be too difficult (that was Barack Obama's position). But that's not true anymore.

Elizabeth Warren, for instance, has moved from the maybe-someday-but-not-right-now position on single-payer to saying, "Now it's time for the next step. And the next step is single-payer." Kirsten Gillibrand is on board, too. Other potential 2020 candidates like Cory Booker and Kamala Harris seem to be edging in that direction, though they're quite not there yet.

That's often how parties move, and the way that Democrats eventually embraced marriage equality: The politicians equivocate, they're pressed by activists, and eventually they realize the ground has moved underneath them and they take a clearer position. It's in that transition period that the demands from the grassroots for them to get off the fence can become loudest.

That's what's likely to happen between now and 2020, so before we get there, we should understand exactly what we're talking about. First, we should realize that some on the left are going to cry that Democrats are cowardly corporate shills no matter what position they actually take. For one colorful example, I'd refer you to this article decrying Bernie Sanders—yes, Bernie Sanders—as a traitor to the single-payer cause because he said that the most urgent priority at the moment is defeating the Republican health-care bill.

Don't be surprised when a bunch of prominent Democrats come out for single-payer and they're met from at least some people with "Not good enough!" For a certain kind of left activist (many of whom rallied to Sanders's cause in 2016), fighting against a Democratic Party they see as corrupt and impure is the foundation of their political identity. If the party itself moves left, then their demands will move left as well. They cannot be satisfied, because being satisfied would itself be a betrayal of their cause, and their cause is the noble rebellion against whatever Democrats happen to be doing.   

That argument will certainly feature in the 2020 primaries. But the best way around its more ridiculous manifestations when it comes to health care is to get as specific as we can about what each of us thinks about the available options. Because most of the time, we throw around the phrase "single-payer" without saying what exactly it is we're talking about.

At its most fundamental, single-payer means, well, a single payer: that there is one insurer (the government) that pays for all health-care costs. But if your single-payer idea is "Medicare for all," you should know that Medicare is not a single-payer program. About a third of Medicare beneficiaries are enrolled in Medicare Advantage, in which their benefits are administered by private insurers. Many others have private Medigap plans that cover cost-sharing expenses Medicare doesn't.

If your single-payer idea is "what they have in the rest of the industrialized world," well, that's not single-payer either. All those other systems have much stronger government regulation than we do, but they all include at least some form of private payment, some more than others. What unites them is that they cover everyone at far lower cost than we do, and they do it through aggressive regulation and price-setting. But it would be absurd to say that someone who favors a version of the British system is a real progressive, while if you favor something like the French system or the Japanese system or the Dutch system then you're a neoliberal sellout.

So as liberals start to think seriously about this issue, it would behoove us all to define exactly the principles and goals that are important; then we can judge what kind of job each competing system does of accomplishing them. Universal coverage is obviously the most important one; everyone has to be covered, full stop. Another is that the system has to be equitable; if people with lower incomes can only afford plans with huge deductibles, it has failed. At a minimum, there has to be a floor of coverage that no one can fall below. I don't have that much of a problem with rich people buying "concierge care" if everyone else is getting high-quality care; it's only offensive when so many people have no coverage at all. And costs have to be brought down; when an appendectomy costs $16,000 in the U.S. but only $2,000 in Spain, we're getting ripped off. That's because other countries regulate health-care prices in ways we don't.

But let's be clear about something. The reason liberals favor a stronger government role for health care isn't because we think that government control is an end in itself. It's because in certain areas, government is the only vehicle, or the best one, to accomplish important goals. The reason that liberals want an EPA that aggressively moves to constrain pollution isn't just that we like the idea of government bureaucrats, it's that we know that without regulation, private industry will pollute the air and water in ways that threaten our health and the health of the planet. At the same time, every liberal knows there are plenty of things government shouldn't do. Nobody is proposing that the federal government nationalize the bread industry; a trip to the supermarket will tell you that the free market is doing a pretty good job of satisfying our bread needs.

But we also know that the market in health care and health insurance isn't like the market for bread. We need a strong government hand in health care because the things we want out of the system can't be achieved without it. That means, however, that when we each come up with our list of goals, there will probably be multiple system designs that satisfy them. Once we admit that—and that it isn't "single-payer" or nothing—then we can start to ask other questions. What would the transition from our current system to another system involve? How long would it take? How much more is it going to cost? What sorts of interim steps (like expanding Medicaid) can help us get there? What kind of political resistance can we expect, and what's the best strategy to confront it?

If you haven't thought about those questions, and your only answer to what we should do about health care is to repeat the words "single-payer," then you just aren't serious about this challenge. We may actually have a chance in the near future to move ourselves on a path to the kind of health-care system that people in other wealthy countries enjoy. So let's not blow it.