Did Democrats mean to become the single-payer party?

Somehow in the decades-long debate about how to keep Americans healthy, we’ve lost track of the difference between health care and health insurance legislation and managed to conflate “universal coverage” with “single payer.” Now Sen. Sanders, in his perpetual search for moral superiority and political isolation, introduced a single-payer “medicare for all” health bill in the Senate. Rather than staying on offense on the Affordable Care Act, keeping more Americans covered, and using the leverage of having Republicans on their back foot for the huge series of legislative battles coming this Fall, we are about to walk chin first into a battle about socializing medicine that will put us back on defense.

Single-payer is pithy and bumper sticker ready. It is a fantastic way for Sen. Sanders to raise money and maintain his profile on yet another issue with no path to implementation. (This bill barely even hints at a funding mechanism.) And he’s created a perfect way for unimaginative 2020 hopefuls to mindlessly brandish their “progressive bonafides” without ever having to do anything or even consider actually implementing something. (Unless one of them manages to get themselves elected President and then this becomes their “repeal and replace” albatross.) Some people will argue that Sen. Sanders is pushing the Overton window out on this issue to create space for better compromises. He may be doing that accidentally, but I doubt that that is his intention and in the meantime he is squandering leverage we need in favor of an idea that has no future. But even if the politics weren’t terrible, is this really the best path to more coverage and healthier Americans?

Beyond the dubious political calculus, I am exceptionally skeptical of a single-payer plan as Sen. Sanders proposes. The elimination of private insurance for anything except elective, non-medically necessary care will fundamentally weaken the quality of care in our system. How will medicine at the level of the Mayo Clinic function under such a system? Without exploding taxes and government budgets, is it possible to provide that level of care to every single American? Do we even have the facilities, resources, and talent to do it — even if we could pay for it?

There will always be a gradient of quality in a country as big and diverse as the United States. We should return our focus to universal coverage and then steadily raise the floor of the quality of care — not introduce a whole new system that will irreparably pull the ceiling down. Yes, we should make Medicare better and fund it properly. Yes, we should make Medicare available to everyone. In fact, if we build on the individual mandate in the ACA with a public option, we can make enrollment in Medicare standard, default coverage for 100% of Americans. There we have it — universal coverage. People can then opt-out of the public option if they choose to buy private coverage or opt-in to a group plan from a vibrant, carefully regulated private market. But no one is uncovered, and we work to ensure that that base coverage is exceptional. Universal coverage and choice — the UK system in a nutshell. Perfect? No. Gold-plated care for everyone? Not yet. Do we need to invest in Medicare and address the overt incentives on hyperspecialization? Yes. Do we have to create a system of regulations to ensure those private plans are fair and have Americans health as a first priority? Yes. Can we create a set of rules that enable a thriving private market without simply moving all the high-risk and low-income patients on to the public option? Yes. The point is there are better options than single-payer, government-only healthcare closer to our grasp that we’re just not reaching for.

While focusing on a narrow, overly simplified solution to an exceptionally complex problem, progressives always decry that the only people who fight against single-payer health care are insurance companies, medical device providers, and drug companies. (Senator Sanders will throw Wall Street in there too out of habit.) False. This is not another version of corporatists versus the people. Another community that tends to hate this whole idea is people who deal with catastrophic illness. My wife is a cancer survivor. If she ever got sick again, I want the option of the best care in the world and would do anything to figure out how to get that for her. Does everyone have that ability or privilege? Unfortunately not. Were we incredibly lucky to have access to the kind of care that saved her life the first time? Absolutely. Should we work our asses off to ensure that more and more people have access to better and better options? 100%. But I’m not willing to take that away from anyone in the interim. If your spouse or child got sick, is Medicare as you know it now what you’d want for them? Are you really comfortable killing off those high-end options? Doesn’t pulling down the ceiling dramatically reduce the potential for innovation and advancement in clinical care? Government should provide the public good and guarantee coverage for its citizens but that does not require dismantling all private options or forgoing the US’s position as the source of the best high quality care anywhere in the world. During the ACA battle in 2010, we were focused on covering everyone — somewhere along the way we lost the script. We can do better for everyone in this country and, as usual, doing what’s best for everyone is better politics than defining questions of life and death as a wedge.

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