emergency sign health care
Credit: iStock

Reid Epstein writes that, while on the campaign trail, Sen. Elizabeth Warren is expressing support for single payer health insurance.

Blocking the GOP rollback of provisions in the Affordable Care Act, Ms. Warren said, is not enough. She said Democrats on the ballot in the next two federal elections should back a national single-payer health-care plan.

Astead Herndon points out that this is a change in position for the Massachusetts senator. But as Ezra Klein recently noted, that mirrors the rumblings that several people are reporting among Democrats on Capitol Hill.

Klein goes on to suggest that Democrats have traditionally been divided on health care into two camps: incrementalists and transformationalists. In describing the former, he says this:

The crucial fact about this divide, however, is that many of the pragmatic incrementalists are philosophical transformationalists: They would prefer a Medicare-for-all system, but they haven’t thought it’s politically possible.

While I have typically favored an incrementalist approach, I have to disagree that when it comes to single payer, the main obstacle is whether or not it is politically possible. Most progressive achievements started off as politically impossible, that’s nothing new. The difference between incrementalists and transformationalists is in recognizing the length of the struggle and the importance of articulating the steps it will take to get there.

I don’t like the idea of engaging in bothsiderism, but there is a way in which all of this talk about single payer reminds me of how Republicans promised to repeal and replace Obamacare for eight years. As we’ve seen, slogans like those tend to appeal to the base of a party. But when/if the time comes to actually deliver, you better have an actual plan in mind. I’m very curious whether or not Sen. Warren and the other Democrats who are ready to sign on to single payer have done the legwork. If not, here are the big questions that need to be addressed:

1. Are we talking about single payer, Medicare-for-all, or Medicare/Medicaid buy-in?

Single payer means that there is only one insurer—the federal government. When Bernie Sanders talks about Medicare-for-all, he actually means single payer, because anyone who is familiar with the insurance program for elderly in this country knows that private insurers still play a pretty big role in that system. Ezra Klein wrote why that is an important distinction, especially on the issue of cost controls.

The role of private insurers matters because it drives the government’s bargaining power. If drug companies either sell to the government or they go out of business, then the government can get better prices. The problem there is obvious, though: What do people do if the government doesn’t cover a treatment they need? But if there are private insurers selling add-on policies to wealthier Americans, then drug companies can deal only with them, and the government’s negotiating power wanes.

The third option of Medicare/Medicaid buy-in is what might be called a “public option” addition to our current system. As an incrementalist, that appeals to me as the next logical step on the way to universal coverage.

2. How much will it cost?

In order to determine how much a program will cost, one of the three options above needs to be chosen, along with a plan for what will/won’t be covered and what out-of-pocket costs will be.

We’ve now had two states and one presidential campaign take a stab at addressing those questions. All three were single payer models, with Sanders and California being very comprehensive and Vermont only slightly less so. The Vermont plan was abandoned because it was too expensive, the California plan was tabled for the same reason, and the numbers in the Sanders plan didn’t add up. We should probably also note that the Nevada legislature passed a bill that would have implemented a Medicaid buy-in. But the Republican Governor vetoed that piece of legislation before the specifics could be determined.

I wouldn’t suggest that Democrats need to iron out a thousand-page document detailing a plan. But it would be critical to study the options and lay out an honest proposal of what would/would not be included and a general idea of how much it would cost. The worst thing that could happen would be for candidates to run on single payer only to get into office and repeat what happened in Vermont and California. That would give voters a reason to never trust Democrats on the issue of health care again.

3. Who would pay how much?

In detailing what happened in Vermont, Sarah Kliff hit on the big obstacle that could derail any attempt to pass single payer.

This is an underappreciated fact of policy change, where even reforms that mostly create winners can still lead to a lot of angry losers. Even if many of Vermont’s residents and business would have paid less under the new plan, many others would have paid more — and they organized to stop that from happening.

It is possible to make generalized statements about what individuals and businesses pay for health insurance under our current system versus what they would pay under a single payer plan. That could very easily point to how the “good guys” win by paying less and the “villains” lose by paying more. But that isn’t reality. Our current system is such a patchwork that an awful lot of people live in the world of exceptions rather than the rule. Under that reality, many of the good guys could end up paying more and the villains less.

Of all the challenges faced by advocates of single payer, this is the one I have the most difficulty imagining a way around. Perhaps it’s the incrementalist in me, but the closest I come is thinking that a step like Medicare/Medicaid buy-in combined with the current exchanges begins to eat away at the ties between health insurance and employment, opening the door for increasingly fewer casualties in transition.

Somewhere in D.C. I sure hope that there are some politicians hammering out a plan (or several plans) that address these questions—perhaps with the help of one of those think tanks. I would personally have trouble supporting a candidate who espoused single payer but wasn’t prepared to offer the outlines of a plan. If they’ve put some thought into addressing these questions though, the moment might be right in 2020.

Nancy LeTourneau

Follow Nancy on Twitter @Smartypants60.