the national interest

How Graham-Cassidy Would Make Single-Payer More Likely

Lindsey Graham wants to reorder the U.S. health-care system for the purpose of trolling Bernie Sanders. Photo: Andrew Harrer/Bloomberg via Getty Images

Perhaps the oddest thing about the last-ditch Republican plan to repeal Obamacare is that it is being sold not as a repeal of Obamacare — which is popular — but instead as a rebuke to a law that does not yet exist. “If you want a single-payer health-care system, this is your worst nightmare,” Lindsey Graham has boasted of his plan. “Hell no to Berniecare.” Graham’s weird promise that his plan “ends single-payer health care” has somehow taken hold, to the point where Republicans appear to believe it would foreclose even public debate on left-wing alternatives. The bill “stops us from having conversation in the future about Medicare for all,” claims Senator Tim Scott.

It is bizarre to believe that directing power from the federal to the state level is irreversible. For an example of a major health-care law that federalized the role of health-care funding and regulation, we merely have to look at … the last one. To be sure, if state-based health-care regulation creates a paradise of universal coverage and low rates, then nobody will have much incentive to change it. But Republicans have zero examples of any such experiment working, and no reason to believe that lower funding levels will do anything other than reduce the amount of care.

Enacting a massive legislation change with unmeasured but far-reaching effects in order to preempt future legislation is an act of incredible irresponsibility. But what’s most perverse is that it fails the test of internal logic. To the extent that the passage of Graham’s bill will affect the chances of Medicare for All passing soon, it will be to make it more rather than less likely.

Democrats in Congress are in the early stages of a partywide debate over their legislative priorities should they regain control of government in 2021. They see two main obstacles in the path of passing a Medicare-for-all bill. First, the Senate filibuster restricts the ability of a major party to write sweeping legislation without a supermajority (which Democrats are unlikely to obtain). Second, the political costs of voting for some kind of single-payer program, which would disrupt existing arrangements for more than 100 million people and/or include large tax increases, would be very steep.

The internal Democratic debate concerns whether it is worth taking on these costs. Senate institutionalists are loath to alter the chamber’s rules to weaken or abolish the filibuster. And many Democrats shy away from the costs of a large welfare-state expansion. What bolsters their hesitation is precisely the assumption that Obamacare is working well. As Bill Scher argued very recently, “[W]hy should Democrats prioritize junking what was just successfully defended, at enormous political risk, when there are so many other moral imperatives that warrant a robust and urgent policy response?” If Congress passes a bipartisan bill to fund the state exchanges, and the Trump administration’s sabotage efforts fail, Democratic advocates of maintaining Obamacare would be vindicated.

What could alter that internal calculus? If Republicans repealed Obamacare. It would make it easier for the left to argue that the program’s compromise structure is a failure, that its markets are inherently susceptible to sabotage by Republican administrations, and that the risk of political capital is worthwhile. And the method used to pass repeal — a hastily assembled reconciliation bill devoid of serious analysis — would make fools of the party’s Senate institutionalists. Democrats would be incentivized to pass a sweeping 50-vote Medicare expansion, with the goal of creating as many beneficiaries as possible, as quickly as possible.

Heightening the contradictions of the system is a longtime tactic of radicals on the left. How strange to see this very dialectic embraced by the far right.

How Graham-Cassidy Would Make Single-Payer More Likely