Last week, the California state senate passed a single payer healthcare bill with a price tag of $400 billion annually. Even with a liberal super-majority in the state legislature the odds of the bill becoming law are close to nil. Even Governor Jerry Brown has signaled serious concerns with the bill and its lack of a funding mechanism (to the tune of billions of dollars).
California Democrats are not alone in this. Cast out of power in the states and DC the party is looking for something to rally around. Many of the party faithful only defended the ACA because they felt they had to. They only loathe the AHCA more because it rolls back protections created by the ACA and it rebukes the legacy of a Democratic President.
At the national level, there is no chance the idea becomes law in any form. The costs of a single payer system nationally could be in the trillions and the logistical and policy obstacles might be even worse. Not that this matters much to liberals.
Talk to many rank and file state legislators, policy experts and national leaders and clearly they feel the ground has shifted leftward in the party on the issue. For example, in the House, virtually every Democrat endorsed a single payer system in their Progressive Caucus’s platform.
In a sign of just how much the party faithful (ie. base) care about the issue, activists tried to shout down California lawmakers and Democratic leader’s at the state party’s Convention in May. While California activists can scream all they want the odds of it becoming law even in blue California are small (see above).
The idea of a single payer system does not just appeal to liberals, however. In rural Minnesota, Congressman Rick Nolan (D) has expressed support for the idea of a single payer system (at least at the state level). Nolan vehemently opposes the AHCA and is more of a traditional liberal that warns his party of being too cautious when it comes to opposing the GOP.
Nolan’s view is not necessarily unique among traditional progressives. Support for the free market, fully embraced by many conservatives, is tempered with a belief that the government can and should fix the ills of the market. Hence, if healthcare needs are not being filled by the free market the government has a role and a responsibility to intervene. In the case of single payer healthcare, the question is how much intervention? Something like the ACA or a full-fledged takeover of the system?
California is not alone in proposing a single payer system. In the blue state legislatures of New York, New Jersey, Rhode Island Massachusetts, bills have been proposed to bring the idea to fruition. Only in California does the idea seem to have a shot, though not much of one.
But, even there, the bill has serious issues. The cost is estimated to be around $400 billion annually and would significantly enhance comprehensive access to healthcare and mandate no out of pocket costs for residents. California is fortunate to have about half of of a single payer’s cost being spent on current programs that could be diverted but the rest would need to come from raising taxes. Not even California could stomach a $200 billion tax hike.
Even if the Trump administration allowed federal funding to be diverted to the program the remaining difference would still be significant. Then there are the issues of care itself. What kind of care would patients receive and what services would be available? You might be able to get a mammogram for free but you might have to wait months on end for a life-saving surgery even if you had the money to pay for it under the old system.
Democrats contend the Trump administration’s pursuit of removing the ACA’s protections has upended the conversation. With party activists feeling like the GOP is hell-bent on removing any federal presence in healthcare (a lie to be honest) they feel they must go all-in on single payer.
But while activists are enthralled by the idea those who worry about the electoral health of their party have serious concerns. Making the idea of a single payer system front and center in the political debate might backfire. Republicans might be able to pivot from the unpopularity of the AHCA to attack a new government takeover of the system.
Nancy Pelosi might be tone-deaf to the needs of red-state Democrats but even she seems to sense the idea of a single payer system might be damaging in purple areas. Asked by reporters last month whether Democrats would make single payer a theme in 2018 she replied with a flat “no” and added, “The comfort level with the broader base of the American people is not there yet.”
Backing up Pelosi’s beliefs are two factors. First, the public really does not seem to be comfortable with the idea of a single payer system. A Pew survey from January found only 28 percent of Americans were comfortable with the idea of government being the sole provider of care. Not even a majority of Democrats, only 40 percent, agreed with the idea.
Secondly, the legislative majorities provided in Congress to make such an idea a reality are virtually impossible to achieve. Right now, the Democratic Caucus is incredibly homogeneous ideologically. But they are 24 seats buried in the minority and to win a majority in the House (to say nothing of the 60 seats they would need in the Senate) they would have to win red and purple areas with millions of voters unsure about a single payer system.
These factors have long complicated and tempered Democratic leaders expectations on healthcare. Despite campaigning on a single payer system in 2008, Obama never tried to implement it once in DC and seeing the composition of the Democratic majority. Hillary Clinton challenged Bernie Sanders again and again last year on the idea a single payer system could ever pass Congress.
Democrats and liberals can take solace in one belief among the public. About three in five Americans believe the government has a responsibility to ensure people have access to care. The problem is, as Bernie Sanders put it, access to care does not mean you can acquire it. In this case the base is unwilling to settle for incremental gains.
Democratic legislators have responded in force. In the House, 112 of 193 Democrats have co-sponsored a single payer bill called the “Expanded and Improved Medicare for All Act.” The bill has been around for years, but until January, it had never seen such a swell of support from the party.
The bill would effectively void the private health insurance system (costing the nation thousands of jobs) and impose new taxes on the wealthy and investment income to pay for benefits. Additionally, the bill would strip private health insurance from millions of people and shift the coverage to the government. Symbolically, the bill found support in the form Joseph Crowley who is Chairman of the Democratic Caucus.
But, even then, the logistical hurdles of the law would be enormous. Educating millions of Americans on what is/is not covered, what benefits they receive, where they can receive care and getting them comfortable with the idea would be massive.
At least at the state level, Democrats would have ideas to build on. But, right now, without a single working model to build on, Democrats in Congress would be building a system from scratch.
All things considered, despite the hurdles involved implementing single payer seems more likely to occur at the state than federal level. Asked whether he thought single payer could pass Congress in the next two years Mr. Crowley replied no, saying, “You cannot get this done with 110 votes.”