Vital Signs Blog

Blog: Imagining the single-payer brawl under President Sanders

Sanders Sanders AP
In South Carolina's primary this Saturday, Hillary Clinton might strike a powerful blow against Democratic presidential opponent Sen. Bernie Sanders, putting his single-payer government health insurance plan into deep freeze.

Clinton's leading by an average of 24 percentage points in the latest South Carolina polls. If Clinton does as well as expected there, she's likely to widen her margin in the March 1 Super Tuesday primaries across the country and cruise to the nomination. Sanders hopes to pull off Super Tuesday upsets in Colorado, Michigan, Ohio, and Virginia.

But regardless of Sanders' political fate, most Democrats will continue to hold out hope for adoption of a Medicare-for-all system to replace the Affordable Care Act. They argue, with considerable evidence, that the ACA has failed so far to make healthcare available and affordable to all Americans. Polls show many Democrats would like to see a single-payer insurance system.

The problem is that even if Sanders wins the nomination and ultimately becomes president, most of the healthcare industry, not to mention Republicans and some Democrats, would fight fiercely against his single-payer proposal.

“The entire supply side of the medical economy would be opposed to efforts to increase the bargaining power of the government and to set prices and terms of care,” said Harold Pollack, a liberal healthcare policy expert at the University of Chicago who supports Clinton's approach of improving and expanding the ACA.

It would be tough to simply establish a government-run insurance plan to compete against private insurers, which Clinton this week said she supports and which Pollack favors. "It's a very powerful coalition, including every hospital and every vendor, that will be resistant to a public insurance option. It's hard for me to see a near-term path to single payer.”

There are, however, exceptions within the healthcare industry. The California-based National Nurses United, a union that claims 185,000 members, recently endorsed Sanders and expressed support for his single-payer plan.

During the Feb. 11 debate between two Democratic candidates, Sanders argued that the country could get a single-payer system that would guarantee affordable healthcare for everyone “if we have the courage to take on the drug companies and have the courage to take on the insurance companies and the medical equipment suppliers.”

Clinton countered that she had battled the pharmaceutical companies and insurers in her unsuccessful effort to pass healthcare reform during her husband's administration in the 1990s. She said she's a staunch supporter of Obamacare, even though it hasn't covered all Americans, “because I know how hard it was to get that done…. We are at 90% coverage. We have to get the remaining 10. I've set forth very specific plans about how to get costs down, especially prescription drug costs.”

As one commentator put it, the Clinton-Sanders health reform schism within the Democratic Party represents “a clash between those who have been in the trenches of trying to make public policy for the last seven years versus those who can exist in a kind of theoretical world of imaging what public policy ought to be.”

Of course, a President Hillary Clinton also would face an uphill battle in passing her more moderate proposals to help consumers with their out-of-pocket medical and prescription drug costs if Republicans maintain control of the House, which they are almost certain to do in the November elections.

And her new proposal to work with governors to establish a public health-plan option in their states promises tough confrontations.

At least one observer said her healthcare plans are no more politically realistic than Sanders' single-payer plan. “Clinton is also making promises on healthcare she can't keep,” U.S. News columnist Pat Garofalo wrote.

But Chris Jennings, a Democratic healthcare strategist and former senior adviser to the Obama and Clinton administrations, argues that Clinton would have a better chance than Sanders of passing health reform legislation in Congress because some of her proposals have support from powerful healthcare stakeholder groups. Many in the industry want to see expanded insurance coverage, with health plans and providers getting the benefit of market share improvements and premium stability.

“There will be policies stakeholders oppose that I think she can win on, and there will be things she will lose on,” he said. “That's how the real world works in Congress. If someone says there will be a Republican Congress and she won't be able to get anything done, that's just not true.”

In contrast, he predicted, healthcare stakeholders would go all out against Sanders' single-payer plan because “they would view it as a threat to their existence. Insurers would go to the mat on that. All the providers and many of the business groups would be concerned about disruption in the current system. Device manufacturers, wholesalers, pharmacies and others would be very concerned about reimbursement rates. This would make the fight against the Health Security Act (the 1993 Clinton administration health reform bill) look like a birthday party.”

Meanwhile, a leading Wall Street analyst, Jeffrey Loo of S&P Capital's IQ, argued this week that a Hillary Clinton presidency, coupled with continued GOP control of Congress, would be best for healthcare investors. “Overall, we believe the best scenario for healthcare investors is a Democrat, presumably Hillary Clinton, winning the Presidency,” Loo wrote. “We believe it is highly unlikely Clinton will be able to pass these initiatives through a Republican-controlled Congress. Conversely, the Republicans' efforts to repeal (the ACA) would be thwarted by a Clinton veto…”

One painful lesson health reformers, including President Clinton and President Obama, learned, Jennings said, is that “people are far more afraid of losing what they have than gaining something someone says they'll get.” Trying to pass single-payer “would be an enormous undertaking requiring extraordinary political capital that would inevitably end in failure and undermine attempts to improve the ACA.”

That's apparently the conclusion President Barack Obama reached. Obama, who spoke favorably about a Medicare-for-all system before becoming president, ruled it out in July 2009 during the debate over the ACA legislation. While saying he would favor single payer if he were starting "from scratch,” shifting completely from an employer-based private insurance system to a single-payer system “could be hugely disruptive.… We should be able to … create a uniquely American solution to this problem.”

Still, even if Bernie Sanders does not become president and does not push through a single-payer system, don't expect those Democratic hopes and dreams to die. They'll just go into hibernation.


Loading Comments Loading comments...