by Graham Vyse | Originally posted at New Republic

Early in her campaign last year for the Democratic presidential nomination, where she cast herself as an experienced pragmatist against fanciful socialist Bernie Sanders, Hillary Clinton dismissed the Vermont senator’s proposal for single-payer health care. “I want you to understand why I am fighting so hard for the Affordable Care Act,” she told a Des Moines audience just days before the Iowa caucuses. “I don’t want it repealed. I don’t want us to be thrown back into a terrible, terrible national debate…. People who have health emergencies can’t wait for us to have a theoretical debate about some better idea that will never, ever come to pass.”

At the time, Clinton’s comments reflected the consensus of the party establishment: Single-payer was an appealing policy, but a pipe dream politically. After all, President Barack Obama had abandoned his support for the idea when he embarked on health care reform in 2009, knowing that many members of his own party would oppose it.

But a lot has changed in the year and a half since Clinton dismissed single-payer—a.k.a. “Medicare for all,” in which the government would pay for everyone’s health insurance—as pie in the sky. Democrats lost the White House, putting them fully in the minority and rendering all progressive policies as equally pie in the sky, at least for a few years. President Donald Trump, who promised voters he would “take care of everybody” on health care, is doing no such thing: Republicans are attempting, haltingly, to deliver on their years-long promise to repeal Obamacare, while also sabotaging the law to give truth to their lies that it’s collapsing.

“Democratic politicians I never thought would utter the words have mentioned single-payer to me in a non-joking way of late,” Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University, recently told Vox. As The New York Times reported last month, Democratic “leaders say the party has plainly shifted well to the left on the issue.” That’s true not only among the party base, as polling shows growing support for single-payer, but in Congress as well. Michigan Congressman John Conyers’s Expanded & Improved Medicare For All Actnow has 113 co-sponsors, out of a total 193 Democrats in the House. And Sanders plans to introduce single-payer legislation in the Senate, where it will have the high-profile support of Elizabeth Warren and Kirsten Gillibrand, both 2020 presidential prospects who recently have urged the Democratic Party to embrace Medicare for all.

It’s an exciting moment for longtime advocates of single-payer, but a perilous one, too. A recent Kaiser Health tracking poll found that “while there has been a modest increase in the public’s level of support for single-payer in recent years, a substantial share of the public remains opposed to such a plan, and opinions are quite malleable when presented with the types of arguments that would be likely to arise during a national debate.” Recognizing this, Republicans are wasting no time in attacking single-payer. “Facing a widespread voter backlash over the House and Senate repeal bills,” The Washington Post reported last week, “they’re trying to make universal coverage a political anchor for Democrats by asking whether they can seriously defend trillions of dollars in new taxes and spending.”

Advocates are confident they can seriously defend Medicare for all. “If Republicans think they’re going to score political points by linking Democrats to single-payer,” said Adam Gaffney, a national board member of Physicians for a National Health Program, “they’ve got another thing coming.” Here’s how he and other single-payer supporters hope to convince the public.


The Republican attack on single-payer is brilliantly simplistic, focusing on just a single number: $32 trillion. That’s how much additional government spending would be needed to pay for the program, according to the GOP, which cites an Urban Institute analysis of Sanders’s plan.

“When you look at the majority of House Democrats, they support a single-payer, $32 trillion bill backed by Bernie Sanders,” White House press secretary Sean Spicer said last month, according to the Post. “We need to accept that Obamacare is dead, we need to understand that the reality is that what the choice is between putting in a system that is affordable and accessible, or a single-payer $32 trillion health-care plan that the majority of House Democrats support.”

“I think Sean Spicer is right,” Conyers said in a statement to the New Republic. “We should thank him and adopt his framing: the choice is between Medicare for All, a program that guarantees healthcare to every American at a price cheaper than what we pay now, or the Republican monstrosity that Paul Ryan and Mitch McConnell are currently ramming through the Congress that would strip away protections for pre-existing conditions, allow insurers to offer barebones plans that cover practically nothing, and slash Medicaid which will result in the deaths of thousands of poor people in order to fund a tax cut for millionaires and billionaires.”

Sanders’s aides told the Post that the senator’s “upcoming bill will have a lower price tag and cost-sharing measures that will be easier to sell,” but nonetheless, reporter David Weigel wrote, “any single-payer plan will require a tax increase larger than any on which Democrats have run since the Great Depression.”

That certainly sounds alarming, but single-payer advocates argue that those costs are more than covered by savings elsewhere.

“This means new taxes,” Gaffney acknowledged, “but it also means the end of premiums, the end of deductibles, the end of copays, and it means never having to deal with another medical bill again.” He added, “If you are spending more in taxes, but your premiums go down more than you’re spending in taxes, then you’re net benefiting.”

“There is simply no critique you can make of single payer health care that is more wrong than ‘It’ll be too expensive,’” Paul Waldman wrote at the Post’s Plum Line blog. “That is 180 degrees backwards. Single payer is many things, but above all it is cheap. And what we have now is the most expensive system in the world, by a mile.” He explained, “Right now, if you’re like most working-age Americans, you pay thousands of dollars every year to insurance companies. If we switch to a primarily government-funded plan, you’d pay for it with taxes, but you’d be relieved of what you now pay to insurers.”

Robert H. Frank, an economics professor Cornell University, used the following analogy in The New York Times:

[S]uppose that your state’s government took over road maintenance from the county governments within it, in the process reducing total maintenance costs by 30 percent. Your state taxes would obviously have to go up under this arrangement.

But if roads would be as well maintained as before, would that be a reason to oppose the move? Clearly not, since the resulting cost savings would reduce your county taxes by more than your state taxes went up. Likewise, it makes no sense to oppose single-payer on the grounds that it would require additional tax revenue. In each case, the resulting gains in efficiency would leave you with greater effective purchasing power than before.

To be sure, funding single-payer will require difficult tradeoffs. For instance, if Medicare for all were funded by a VAT tax, it “would be paid by everyone, including senior citizens who already have Medicare,” Vox’s Matthew Yglesias wrote. A payroll tax is another option:

Employees would see take-home pay fall thanks to the new tax, and employers would be relieved of the cost of providing health insurance. In theory, that cost-saving ought to pass-through to workers in the form of higher salaries over the long-term.

But that’s asking citizens to take a pretty big leap of faith. And even if average wages do rise, that’s not a guarantee that your wages in particular will rise. This is a particular problem for union workers whose pay and benefits are set in collective bargaining agreements, which in turn is a huge political problem since it’s difficult to imagine ambitious new social welfare legislation being enacted without union support.

But even rebutting Republican claims of a $32 trillion price tag is, in a way, to debate single-payer on their terms. “It’s really important for progressives and socialists not to accept conservative frames about tax cuts and spending,” David Duhalde, the deputy director for the Democratic Socialists of America, told me. “We would address it not using their frame. We would say this is a universal program and that healthcare is a human right.”

The polling shows that framing is everything. In an analysis in March, The Washington Post’s Philip Bump revealed the many nuances and contradictions in public opinion of health care proposals: “federally funded healthcare program providing insurance for all Americans” is more popular than repealing or keeping the Affordable Care Act. A January poll found that 38 percent of Americans support single-payer, including 51 percent of Democrats. But as Bump noted:

Those results dropped dramatically when respondents were asked if they supported single-payer “if it would result in large increases in government spending.” At that point, only a quarter of respondents supported the idea — including a little over a third of Democrats.

It also might matter what you call it. “Among Democrats, the term ‘Medicare-for-all’ generates a much more enthusiastic reaction than does ‘single-payer,’” Drew Altman, president and chief executive officer of the Kaiser Family Foundation, wrote last year in The Wall Street Journal. “With this discussion still mostly at the stage of broad concepts and messaging, language matters.” He noted that a Kaiser Health Tracking poll “found that 53% of Democrats were ‘very positive’ about Medicare-for-all, compared with 21% who felt that way about a ‘single-payer national health-care system.’” That makes sense, given Americans’ familiarity with Medicare, though Kaiser’s latest tracking poll found “that when the plan is defined as one in which all Americans would get their insurance from a single government plan, support is similar when the plan was referred to as ‘Medicare-for-all’” (57 percent in favor) as when it was referred to as ‘single payer’ (53 percent).”

Representative Tim Ryan of Ohio has a different argument for avoiding “single-payer.” “We think everybody knows what the hell we’re talking about, and nobody does,” he said. In his district, which includes Youngstown and Akron, “My people don’t have any clue what ‘single-payer healthcare’ is.”

What voters would understand, the congressman contends, is being able to buy into Medicare at age 50 or 55, provided they meet a means test. They’d understand that single-payer would be “a good jobs program,” employing occupational and physical therapists in positions that can’t be outsourced. “Those are jobs that can be right here in the United States of America,” Ryan told MSNBC anchor Hallie Jackson last month, “and we’ll be healthier, and prevent a lot of diseases, and bend the cost curve on health care, which is the goal we’re trying to accomplish now.

“We’ve had great success talking about improved Medicare for all that guarantees healthcare,” said Michael Lighty, who directs public policy for National Nurses United. “The best way to solve our healthcare crisis—and it is a crisis—is to rely on a popular program that works. I think that’s the strongest message.”

Lighty added, “I would really emphasize the popularity of Medicare—the breadth of support it has historically, its effectiveness.” (Pew Research recently found that even a majority of Republicans—57 percent—believe the government “should continue programs like Medicare and Medicaid for seniors and the very poor.”)Notwithstanding Medicare’s popularity and growing support on the left for single-payer, some Democrats still oppose the idea—at least during this crucial moment for Barack Obama’s signature legislative accomplishment.

“Discussion of single payer right now is irrelevant at best and at worst a serious distraction from the fight to save Obamacare,” Matt Bennett, co-founder of the centrist Democratic think tank Third Way, told USA Today. “All Democratic energy has to be directed at saving Obamacare. We do not understand why anyone would take their eye off the ball at this moment.” He also called single-payer a “massive expansion of government” that would hurt Democrats with Trump voters.

That’s a dubious claim, given Trump’s long flirtation with single-payer and the polling of his supporters:

Ryan, the Ohio congressman, said that if coal miners and steel workers had earlier access to Medicare, they “would finally see the federal government working on their behalf.” He added, “These guys feel forgotten, and they won’t give a damn whether it’s the Medicare program or private insurance.”

Back when Clinton disparaged single-payer in Iowa, Washington Monthly contributor David Atkins offered the following advice for the next Democratic president:

In an environment where little good can happen legislatively anyway, the best thing a President could do on the healthcare front is make it clear that their party would enact single-payer healthcare if the opposition weren’t standing in the way.

Desire for an improved healthcare system might or might not lead to stronger base turnout in subsequent elections, but in either event the germ of the idea of single-payer healthcare would move from the outside edges of liberal circles to mainstream discourse on the front page of the New York Times. And that in turn means that with enough demographic change and redistricting, single-payer healthcare might actually become a reality by 2030. In other words, just talking about single-payer healthcare from the bully pulpit makes it much likelier to happen over time. Certainly much more so than saying it will “never ever happen.”

Democrats face an even bleaker legislative scenario than Atkins imagined, forced to play defense against Trump and the Republicans while hoping to win back Congress in 2018. But that makes his words even more applicable today.

Some Democrats argue that the Medicare-for-all debate is distracting the party from the urgent need to save Obamacare. “The path to public option, single payer, is in the Affordable Care Act. It is not in distracting us from the focus of stopping what they are doing to let people die,” House Minority Leader Nancy Pelosi, a longtime single-payer supporter, said last month. “It isn’t helpful to tinkle all over the ACA right now. Right now we need to support the Affordable Care Act and defeat what the Republicans are doing.” But surely Democrats can walk and chew gum at the same time. As Conyers said in his statement, “What we cannot do is say it’s a choice between keeping the ACA or going to Medicare for All. Passing the ACA should be seen as a first step toward Medicare for All.”

Democrats can’t afford not to lay the groundwork for policies they would enact if they return to power, and now that single-payer has indeed moved into mainstream discourse, the moment is ripe for the party to stand unified in support of single-payer health care—er, Medicare for all. “Politics isn’t just the art of the possible today,” Atkins wrote. “It’s also about shaping the realm of the possible tomorrow.” Since nothing is possible for Democrats today, all they have is to try to shape the future.