Democrats Must Soon Decide Whether Single-Payer Is a Litmus Test

Even as many Democrats join the single-payer parade, Tim Kaine and Michael Bennet are offering a new, incremental approach to health care called “Medicare X.” Photo: Alex Wong/Justin Sullivan/Getty Images

There has been a simmering debate in left-of-center circles all year about whether Democrats should unite behind single-payer health care as a rallying cry and a litmus test. There is no question there is a trend toward support for single payer among Democratic pols and voters, but the question is whether any other, more incremental, policy prescriptions in health care are now to be excoriated as insufficiently progressive.

Up until now this argument has been relatively abstract: There are all sorts of different forms of single-payer health care (though Bernie Sanders’s Medicare for All proposal is the most frequently cited), and many ways to reform the current system that are less disruptive to the status quo than single payer. But the debate is beginning to congeal in ways that may require Democrats to make some serious choices about messaging and internal party politics.

Most notably, the 2016 Democratic vice-presidential nominee and his centrist Senate colleague Michael Bennet of Colorado have introduced a bill that would create a health-care public option called “Medicare X.” It is not, technically, a Medicare buy-in program; it would simply create a government-backed option on Obamacare individual insurance exchanges that would utilize Medicare’s provider networks and reimbursement rates to provide more affordable policies (and also a backup if private insurers withdraw entirely). Kaine and Bennet would also phase in the “Medicare X” option gradually, so it’s an incremental approach to an incremental system.

In other words, it’s probably the kind of weak tea single-payer advocates love to hate. It doesn’t abolish private health insurance at all (though some might argue that over time a public option would take over the individual insurance market because private plans could not effectively compete), and it suffers from all the problems of complexity that have plagued Obamacare politically. And Kaine, for one, rejects the argument that he’s creating a gradual path to single payer, as he told Vox’s Sarah Kliff: “I like giving people more choices, not less. This is my belief. My constituents are telling me they want more choices.”

The big, obvious advantage of Medicare or Medicaid “buy-in” plans like Medicare X is that they don’t disrupt Americans who are reasonably pleased with their health insurance, and also don’t require enormous tax increases. Yes, Medicare for All would almost certainly improve insurance for all but a small minority of Americans, and, yes, the tax increases might be more than offset by the abolition of premium payments and big out-of-pocket expenses. But these are arguments, not instantly appreciated facts, and any serious push for single payer will face the largest and most expensive campaign of conservative and insurance industry pushback in the history of public policy. A political calamity not just for health-care policy but for Democrats is a distinct possibility.

So the real question is whether progressives should go for broke with single payer, recognizing that all those polls showing it’s so very popular could change dramatically when opponents have a fixed target, and also whether rigid unity is important enough to insist on at the risk of sacrificing some alternatives and backup plans that could prove useful down the road.

If Democrats are going to discuss the range of options constructively, centrists will need to come clean about the extent to which they are catering to corporate donors in finding alternatives to single payer. Leftists will need to decide whether a single-payer litmus test is an instrument for a hostile takeover of the Democratic Party rather than an effective partywide message. As the reliably progressive Joshua Holland wrote in the Nation recently: “it’s time to get past the idea that anyone who doesn’t embrace Medicare-for-All, as it’s currently defined, must be some kind of neoliberal hack.”

The obvious broader message for Democrats is “universal health coverage,” or perhaps “health care as a right.” Either is subject to the objection that many Republicans can claim that their destructive health-care policies will eventually accomplish those objectives with fewer taxes and less bureaucracy (these are, after all, the same people who are currently claiming that cutting corporate taxes is the best way to boost middle-class family income). There’s no question single payer sets out a position that few if any Republicans can co-opt or imitate. And unlike Obamacare or any incremental refinement of Obamacare, it could genuinely excite base voters wanting a clean break with the status quo, while convincing some swing voters to give the Donkey Party a fresh look.

But it’s a risky strategy and one that Democrats would struggle to implement without massive gains in Congress that, at this point, look extremely unlikely. Approaching the goal incrementally may seem cowardly to some. But in politics brains really do matter as much as spine.

Democrats Must Decide If Single-Payer Is a Litmus Test