Washington Post  Plum Line

Whatever happens, the GOP is bringing us a whole lot closer to single payer

By Paul Waldman     June 27, 2017

The Republican health-care bill is not dead yet, but it’s in rough shape. Whether it passes or not, it has been an utter debacle for the GOP, making the Affordable Care Act they’re trying to undo more popular than ever, energizing the Democratic base, complicating the relationship between President Trump and Congress and sowing justified distrust of Republican motives among the broader public.

It has also done something else: moved the debate on health care in America to the left and made single payer much more likely.

Even if the Senate bill fails, Republicans give up and move on to tax reform, and the status quo remains in place, this debate will have had profound effects on our politics. While the Democratic Party may have been moving to the left on health care anyway, its momentum in that direction may now be unstoppable. And the entire country will be more receptive than ever to the arguments Democrats will make. This, by the way, will also be the case if the GOP repeal effort succeeds, because it will make so much that people hate about our health-care system a lot worse.

Let me point to one politician as an illustration. For years, Sen. Elizabeth Warren’s position on single payer has essentially been “Maybe someday” — not opposed to it, but focused in the short term on the more urgent priority of defending and enhancing the ACA. But in an article in today’s Wall Street Journal, we learn that she is now ready to take that plunge:

“President Obama tried to move us forward with health-care coverage by using a conservative model that came from one of the conservative think tanks that had been advanced by a Republican governor in Massachusetts,” she said during an interview in her Senate office last week. “Now it’s time for the next step. And the next step is single payer.”

Warren is not going to be the last Democrat to take this step. In fact, any Democrat who runs for president in 2020 — and there will be a lot of them — will have a hard time explaining to the primary electorate why they don’t want single payer, and most or all of them will probably say they do.

We can make an analogy with what happened in the GOP after the failure of comprehensive immigration reform. In 2013, the Senate passed a comprehensive bill with the support of many Republicans. But after it died in the House, Republican politicians went in exactly the opposite direction, telling their base that the only question was how much they hated “amnesty” and how tough they would be on undocumented immigrants. Then their party nominated someone who said he would build a wall on our southern border, create a “deportation force” and ban Muslims from entering the country.

The situations aren’t exactly the same, but the point is that a dramatic political failure — whether it’s yours or the other party’s — can have profound effects on the choices politicians make about how to approach the electorate. And it’s important to understand that while there are some Democratic politicians who emphatically favor single payer and would be unsatisfied with anything less, most of them would be willing to advocate for a range of policy options, depending on what looks politically achievable and what their base demands at a particular moment.

All the ups and downs of the past eight years, from the beginning of the debate on the ACA to the end of the debate on Republican repeal plans, hold many lessons for Democrats who are still eager to address the problems in the American health-care system. Among other things, we know that voters are risk-averse, that they’re extremely sensitive to out-of-pocket costs, that they want security and that arguments about the glories of the free market aren’t going to be persuasive to them. After seeing how desperately unpopular this Republican plan is, Democrats are going to be much less afraid to defend government health care and advocate its expansion.

And they know that whatever they propose next has to be simple and understandable. We can debate whether the ACA had to be as complex as it was, but next time around, no Democrat is going to believe that you can take on President Trump with a technocratic approach to health care. Saying “Here are the 10 tweaks I’d make to the ACA” isn’t going to cut it.

That isn’t to say that whatever plans they propose won’t be fully fleshed out under the hood, but they’ll have to be presented in a way that is easy for voters to understand. And, yes, Republicans will cry about “Washington bureaucrats making decisions for you,” but Democrats are less likely to be intimidated. Ask your parents or grandparents on Medicare how they feel about their coverage — Medicare is the most popular health insurance program we have, and it’s run by Washington bureaucrats.

It’s important to keep in mind that “single payer” isn’t one thing — if you look around the world at highly developed countries, there is a spectrum of health systems with various levels of public and private involvement. But what they have in common is that they achieve universal coverage while working better and costing less than ours. We could well have 15 Democratic presidential candidates proposing 15 different kinds of single payer. Some may be highly socialized systems — what Bernie Sanders would likely advocate if he runs again — but the ones that are most appealing could be hybrid systems of the kind that have been successful in countries such as France. The way it works is that there’s a government plan that covers everyone’s basic needs, but you can also buy supplemental private insurance to get as many more benefits as you want.

Among the advantages of a hybrid system is that one can actually see a path from where we are now to there. That path runs through Medicaid, which now covers nearly 75 million Americans. What if we auto-enrolled everyone under 65 in Medicaid — it’s there if you need it, but if you have different insurance you’d prefer, go ahead and use that instead. No one would be without coverage. Private insurance would evolve into something you buy to fill in the gaps and get perks that Medicaid wouldn’t provide. Instead of covering all your health care, employers could provide the supplemental private insurance.

As a political matter, you could sell this as something that we could transition to over an extended period, and as a system that satisfies the goals of both liberals and conservatives. Liberals get the universal coverage and security they want, and conservatives get the freedom they want — if you’re rich enough to buy a supplemental plan that includes deliveries of Dom Perignon during any hospitalization, go right ahead.

That isn’t to say that Republicans wouldn’t resist and there won’t be more intense arguments about health care, because they would and there will be. But by handling this debate so terribly and proposing something so monstrous, Republicans have opened up the space for Democrats to go much further than they’ve been willing to before. It’s not impossible to foresee Democrats winning the House in 2018, then taking the presidency and the Senate in 2020 — and then taking the first steps toward making single-payer health care in America a reality.