Eight years ago, as Congress was in the throes of debate over the Affordable Care Act, Vermont senator Bernie Sanders withdrew an amendment to replace the US's current healthcare system with one in which the federal government provides Medicare-style insurance to every man, woman, and child. Republicans trying to block the ACA were forcing the Senate clerk to read the 767-page amendment out loud as a way of stalling debate; Sanders, knowing the amendment was a hopeless cause anyway, pulled it from consideration. (He later voted for the ACA.)
"The day will come, although I recognize it's not today, when the US Congress will have to vote to stand up to… all those who profit every single year off of human sickness," Sanders said at the time. "That day will come."
That day seems closer now. On Wednesday, Sanders introduced a new bill pushing a Medicare-for-all system (a.k.a. "single-payer"), and this one has the support of more than a dozen Democratic senators, more than ever signed onto Sanders's previous bills. No one thinks this bill will pass—it won't even be considered until Democrats control both houses of Congress and the presidency—but it's an important signpost on the road the Democratic Party is traveling, as well as a potential banner to be waved in the 2018 and 2020 elections.
The bill represents an ambitious vision. The benefits it provides to all US residents include dental, vision, and prescriptions, all without copayments—a more generous package than is offered to residents of some European countries. Immediately after the bill's hypothetical passage, everyone under 18 and above 54 would be enrolled in this new, improved version of Medicare; everyone currently on employer-provided insurance would be transferred to the government-run system over the course of four years. After that, the private insurance industry would basically cease to exist. (This gradual implementation is the major concession Sanders made to attract senators worried about the scope of these changes.)
What the bill doesn't do is answer criticism from Democrats who aren't on the Medicare-for-all ship. The anti-single-payer argument has always been 1. How are you going to pay for the trillions this plan would cost? and 2. How do you reassure people who like their employer-provided insurance and don't want to be forced to get with the government program?
In an interview with Vox's Jeff Stein, Sanders largely glossed over the second point, saying, "You go to the doctor you want who will still be practicing in exactly the same way he or she practices today," which sounds perilously close to Barack Obama's infamously wrong pre-ACA promise, "If you like your healthcare, you can keep it." As for the cost, Sanders promised to address that with "a number of revenue-raising proposals, which will generate more than enough money to pay for what we want to do."
But if the debate is now at the point of haggling over how Medicare-for-all should be paid for and implemented, that's already a huge victory for Sanders and his allies. Though polling on Sanders's specific proposal isn't conclusive, a Pew survey from earlier this year found that a record-high 60 percent of Americans say that the government has a responsibility to provide health insurance. The nitty-gritty policy choices are hard, but the broad politics are incredibly simple. People need insurance and expect the government to provide it, so the government should do that—that's what political neophyte Donald Trump said during the campaign before realizing Republicans shouldn't say stuff like that.
The senators who signed onto Sanders's bill, many of whom presumably have presidential ambitions, likely aren't sweating the details. The proposal is more a statement of principals than a potential law—it's the mirror image of Republicans' repeated efforts to repeal the ACA. None of those anti-ACA votes were serious, as became apparent when Trump got into office and the GOP had to write new, more realistic bills. But "repeal and replace" was a valuable rallying cry for the Republican base, the same way that "Medicare for all" inspires liberals.
It also has the potential to answer the question, "What is the core message of the Democratic Party?" That's a big deal, given that one recent poll found that 52 percent of Americans thought Democrats didn't stand for anything beyond being anti-Trump. On that score, Medicare for all makes sense as a cause. Nearly everyone has been frustrated or abused by America's fragmented, overcomplicated, inefficient, often cruel healthcare system. This, from a Sanders op-ed in the New York Times on Wednesday, is some bona fide populism:
Americans should not hesitate about going to the doctor because they do not have enough money. They should not worry that a hospital stay will bankrupt them or leave them deeply in debt. They should be able to go to the doctor they want, not just one in a particular network. They should not have to spend huge amounts of time filling out complicated forms and arguing with insurance companies as to whether or not they have the coverage they expected.
The downside of Sanders's message is obvious if you look at how badly the party of "repeal and replace" fared after they took control of government. "When grandiose promises on the campaign trail aren't kept once attaining power, a party's base becomes demoralized and recriminations follow," Bill Scher wrote in a Politico piece cautioning his fellow Democrats not to go full Medicare for all. That is a fair warning. Maybe Sanders's message is a winning one in 2018 and 2020. Maybe when it's time to actually transform the healthcare system in 2021, however, the country balks and the whole effort fizzles out. Several states have gotten close to true single-payer systems over the years, and none of them have bit the bullet. When push comes to shove, wiping out the insurance industry and jacking up taxes is a scary prospect for a lot of politicians, donors, and change-averse voters.
But Sanders's bill won't necessarily be a failure if it never becomes law. It could be the opening position in a long debate that results in a compromise that pushes American healthcare in a more progressive position. It could do nothing but help define what the Democrats stand for—and the party definitely needs help with that.
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