A Political Argument for Single-Payer

Recently, Senator Bernie Sanders returned to what he does best - making a ruckus. This time, it came in the guise of his sponsoring a bill to create a Medicare-for-all single-payer healthcare system. In a triumph for Senator Sanders, the bill has 16 co-sponsors in the Senate, including potential presidential candidates Kamala Harris of California, Cory Booker of New Jersey, and Kirsten Gillibrand of New York. Its surprisingly wide backing, however, has made it that much more of a flashpoint among Democrats, who are sharply divided on the measure. 

Supporters say it is the logical outcome of the Democratic Party's philosophical statements on healthcare. Those who oppose it do so mostly on political grounds, saying the vast expansion of the role of the state in healthcare would hand Republicans a cudgel with which to hit Democrats in the coming midterm elections. Others point to the herculean effort required to acieve the Affordable Care Act and think it unwise to abandon the only successful attempt to reform health coverage in 50 years. A few Democrats (Joe Manchin comes immediately to mind) have actual philosophical issues with the concept of a single-payer plan, but they are not only a small but also a rapidly decreasing minority in the party, so I will simply note their existence and move on.

The merit of a single-payer health insurance system relative to the current one is a long subject in itself and one I intend to treat in the future. For the moment, I will focus on effectively addressing the political argument against advocating for it.

The first and most obvious counterargument is that the Republicans will accuse the Democrats of wanting "government-run healthcare" or "a government takeover" of healthcare regardless of whether the plan for which they advocate is single-payer or not. The GOP invoked that overheated rhetoric against what was a fundamentally conservative solution to the coverage problem in the Affordable Care Act. That party has fully subordinated its policy notions to political and ideological considerations. Under such circumstances, there is no logic at all to a position that claims a single-payer system is the correct policy but that one shouldn't advocate for it. 

If there was a plausible expectation that the Republicans could be brought to the table on some necessary patches in the Affordable Care Act and thereby set a precedent for cooperative improvements in the healthcare system, the argument against proposing single-payer, which might then put political pressure on otherwise willing partners to withdraw from talks, would have some force. But it took them eight years to develop a health policy more complicated than the word "no," and when they finally did so their abject surrender to political considerations made the bill itself so destructive and incoherent there weren't even enough Republicans willing to enact it. In spite of that colossal and embarrassing failure, they have persisted in the purely partisan attempt at repealing the ACA entirely instead of searching for middle ground.

If, at this late juncture, they have yet to accept the framework of the ACA as the basis for marginal improvements, then the Democratic Party has no reason to throw a sop to insurance companies by propping up the current system. The whole point of the ACA from a political point of view was to build consensus by keeping private insurance, but arranging the markets in such a way as to address the defect of insufficient coverage. But if such marginal improvements in the system of private insurance are too much for Republicans to stomach, why bother with private insurance at all, when our principles tell us that adequate health care ought to be a human right rather than a privilege?

Indeed, if the Republicans are determined to assault Democrats on the healthcare issue as power mad bureaucrats taking over the system, then single-payer is the only option that makes sense for them politically. Activists will applaud the party for taking a moral stand on the issue, and simply by hearing the issue debated openly instead of dismissed in hushed tones the public will become used to the idea. Taking the position would not only unify and energize much of the Democratic Party, but it would prepare the ground for the actual realization of a policy the vast majority of Democrats admit in private is the one they want.