On Wednesday, Bernie Sanders introduced his much-anticipated Medicare for All legislation. It already has 16 Democratic co-sponsors, including potential 2020 hopefuls like Cory Booker, Kirsten Gillibrand, Kamala Harris, and Elizabeth Warren. A third of the Democrats in the Senate now back single-payer, a remarkable swing from just a few years ago. Back then, as Sanders himself put it, “we had me, and that was it.”
But even before Sanders released his plan, liberals were warning that Democrats would be unwise to shackle themselves to a bill that could hurt them politically. Bill Scher, writing in Politico, said the problem is that Medicare for All is “easier to say than to do. When grandiose promises on the campaign trail aren’t kept once attaining power, a party’s base becomes demoralized and recriminations follow.” Margot Sanger-Katz, writing in The New York Times, argued that Medicare for All could become the Democratic Party’s version of the GOP’s “repeal and replace,” an unfulfillable promise that would come back to haunt them:
Like “repeal and replace,” “single-payer” is a broadly popular slogan that papers over intraparty disagreements and wrenching policy choices. Republicans fumbled multiple attempts to replace the Affordable Care Act this year. If the Democrats eventually wrested back power, they could find themselves similarly factionalized and stymied over the details.
And in New York magazine, Jonathan Chait, writing after the bill’s release, said it would hurt Democrats on the campaign trail, too: “At no point does [Sanders] grant that the most important source of opposition will come from actual American voters concerned about losing their current plan or paying higher taxes.”
What these criticisms share is an underlying belief that Democrats are racing leftward on health care for short-term political gain—namely, appeasing the demands of the progressive base—without taking into account the long-term repercussions and whether Medicare for All is even feasible. But Sanders’s proposal is not a cynical slogan like “repeal and replace,” nor is it an inflexible roadmap that will invariably lead to a political dead end. It is better understood as a historic breakthrough in the way that Democrats approach health care, opening the door for all kinds of fixes to a system that nearly everyone agrees is too expensive and too inefficient.
Sanders’s bill would collapse all the existing ways that people get insurance—employer-sponsored, government-run (Medicaid and Medicare), Obamacare exchanges—into a single government plan. Private insurance would largely become nonexistent. The bill would eliminate deductibles and copayments. It would also overturn the Hyde Amendment by including access to abortion insurance.
All this would happen over the course of four years, which is one way Sanders’s bill differs from Representative John Conyers’s single-payer bill in the House, which has 117 co-signers; Conyers’s plan would take only two years to implement. Sanders’s bill also has no funding mechanism attached to it, which will be one of the largest political obstacles to getting it enacted, though Sanders has released a separate list of options to raise the money.
No doubt, this is an audacious bill, with an unheard-of amount of mainstream Democratic support. And, of course, it has no chance of passing until 2021 at the earliest, which makes it easier for Democrats to support now. But just as important as the policy itself are the political implications of the bill, which Sanders has teased in his rollout of the legislation.
The most obvious function of Sanders’s Medicare for All bill is that it is being used to excite the Democratic base as we head into the 2018 midterm elections. A highly cited survey by Kaiser Health Foundation shows that a slim majority of Americans, 53 percent, favor single-payer, including 63 percent of Democrats and 55 percent of independents. Setting up Medicare for All as a goal is a way to activate movement politics, to give people a reason to go to the polls and make phone calls. We have already seen the fruits of those efforts: that 16 senators have signed on to the plan is due more to sustained grassroots organizing than anything else.
But that Kaiser poll has some pitfalls, too. The true opposition to Medicare for All won’t come from wary Democrats (the single-payer campaign got a surprise pick-up this week when moderate Max Baucus endorsed it), but from Republicans, who will demonize the legislation from here to 2018 and beyond. Both Scher and Sanger-Katz point out that the Kaiser poll shows that support for single-payer is malleable, dropping by around a third if people are told that the plan would give the government too much control over health care, eliminate or replace Barack Obama’s Affordable Care Act, or require a tax hike. The ads about higher taxes and a government takeover are a given.
As Chait notes, the most risk-averse voters will likely be the 155 million people who are on employer-provided insurance. Then there are the seniors who already have Medicare and may be vulnerable to messaging that suggests a socialist takeover of the health care system will endanger their coverage.
But the poll also shows that those who initially oppose single-payer can be swayed. If opponents hear that single-payer would reduce health insurance administration costs, support rise from 55 percent to 72 percent. If they hear that it would guarantee that all Americans have health insurance as a basic right, support rises to 71 percent. And if they hear that it would reduce the role of private health insurance companies, support grows to 65 percent. At the very least, voters can be convinced in either direction.
Furthermore, there’s nothing the Democrats could propose that Republicans wouldn’t frame as a tax-hiking, government takeover of health care. Since the GOP has already been making these arguments about the ACA for years, and recently was unable to repeal the very government takeover it had long condemned as an affront to freedom and common sense, it’s more likely these arguments will lose their power as time goes on, not gain new relevance.
The positive reception Sanders has received is evidence that popular perceptions about health care can change. Sanders’s new bill is being taken far more seriously among the media and pundit class than during the primary campaign, when it was nearly universally derided as “puppies and rainbows.” This speaks to a change in the political climate, not the actual policy details of Sanders’s legislation.
The devil, of course, resides in those details. But seeing the inevitable disagreements between Democrats over those policy choices as a mirror image of what happened with the GOP’s repeal and replace is a mistake. Sanders and his progressive supporters could not be more different from the hardline Freedom Caucus. They are pushing Democrats toward a leftist goal, but that is not the same as holding their party hostage to insane demands to take insurance away from tens of millions of people. Repeal and replace was a cynical, partisan reaction to Obamacare, whereas the push for single-payer is rooted in a moral imperative to improve the lives of all Americans.
In this respect, a party that is united in this goal, but divided on the means of attaining it, can still be an effective one. Amidst Sanders’s push for single-payer, we have seen alternatives being developed by other Democrats like Chris Murphy and Brian Schatz, both of whom are committed to the goal of universal coverage. Critics say Sanders’s plan precludes more incremental approaches, but you can also say that the momentum Sanders is building helps generate more of them. On Tuesday night, Topher Spiro, vice president for health policy at the Center for American Progress, a center-left think tank that has focused on bipartisan proposals to shore up the ACA, hinted on Twitter that research related to single-payer might be coming down the pipeline:
Stay tuned
— Topher Spiro (@TopherSpiro) September 13, 2017
As Sanders told Jeff Stein at Vox, he won’t criticize his fellow Democratic senators who are against the bill, saying, “Many of my Democratic colleagues have had to sustain zillions of dollars of dishonest Republican 30-second ads. They will make the case that they can to their constituencies.” There may be an intraparty debate, but so far it has been a civil one.
Sanders has shown a deft political touch during this campaign, suggesting that he is not the rigid ideologue his opponents make him out to be. As Jeff Stein notes at Vox, the fact that Sanders’s bill phases in over four years rather than instantaneously shows that he can make “small but meaningful concessions to create a bill that would still create Medicare for All without making it so radical Senate Democrats couldn’t support it.” Four years is still an enormously quick transition, but a tradeoff at this very early state carries added weight when you consider that the bill is mostly an ideological blueprint.
Sanders has also taken grief for failing to attach a funding mechanism. “A nonspecific health-care plan that lacks a plausible financing system has accomplished approximately zero percent of the necessary work, as the Republicans discovered this year,” Chait writes. But another way of looking at this is that Sanders, by opting to roll out different funding options separately, is shielding his co-sponsors from signing on to a politically toxic price tag. It is the kind of thing a politician does when he is trying to get his colleagues to “yes.”
As HuffPost’s Jonathan Cohn argued in advance of the release of Sanders’s bill, it would be best if Sanders presents his plan as “a starting point for a conversation that will take place among politicians and activists and wonks over the course of many years.” So far, Sanders has proved that he can be a team player—Cohn points out that he worked to protect the ACA during the GOP’s recent repeal and replace effort, rather than using it as an opportunity to tout his own single-payer plan. The progressive grassroots also mobilized in full force to protect the law.
Sanders has blown open the door to single-payer, which necessarily allows a lot of dangerous GOP opposition to fly in. The question is whether or not Sanders and other Democrats will be able to maneuver that opposition. But it also opens the door to a lot of other options to get to universal coverage, in an atmosphere that did not exist before. Sanders may not have figured out the way to single-payer just yet, but he has shown that having the will to do so is equally important.