What's behind the renewed enthusiasm in the Democratic Party for Sen. Bernie Sanders' single-payer healthcare bill? The GOP still controls both houses of Congress and the White House. The Affordable Care Act still faces an existential crisis.
Unless something is done in the next few weeks to shore up the exchanges for 2018 and reverse HHS' mean-spirited efforts to undermine enrollment, the enormous progress made over the past four years—last week the Census Bureau announced the nation's uninsured rate had dropped sharply over that period to 8.8%—will begin to reverse. For those desperately working to avert the immediate danger, single-payer advocacy is a distraction.
Unfortunately, the logic of contemporary politics made the current push for single-payer inevitable. President Donald Trump and the tea party set the table. They proved that in a populist moment, extreme positions that cater to a sliver of the electorate are a viable path to electoral success.
Expect left-wing challengers supporting single-payer to win numerous Democratic House and Senate primaries next spring. A wave election typical of first-term, off-year elections will lead to a single-payer caucus in the next Congress with as much power as the tea party caucus had after the wave of election of 2010.
Single-payer looms as their threat. If you destroy President Barack Obama's grand compromise-his namesake plan relied on private insurers and preserved the employer-based system- the fire next time will get rid of both.
Unlike the tea party, single-payer advocates have history on their side. The U.S. over the last half century has moved inexorably toward universal coverage: Medicare and Medicaid; the Children's Health Insurance Program; the ACA. It will get there one way or another.
Sanders asked the right question in his op-ed last week in the New York Times. "Do we, as a nation, join the rest of the industrialized world and guarantee comprehensive health care to every person as a human right?"
Polls now report growing support for single-payer health insurance. When asked if the government has the responsibility to guarantee access to healthcare for all Americans, nearly 60% answer yes. In other words, a clear majority of Americans now say yes to Sanders' question.
It's not just a human-rights issue. Universal access through universal insurance coverage is a necessary if insufficient component of getting healthcare costs under control. It is also a building block for restoring the nation's economic competitiveness, especially in areas of the country suffering from a prolonged decline. No region can thrive unless it has a well-educated, healthy workforce.
Industrialized countries diverged in how they achieved universal coverage. Some chose a government-funded, single-payer system. Others chose well-regulated private insurers. Still others chose a combination of the two.
The U.S., because its employers used health benefits to get around World War II's wage-and-price controls, accidentally chose a mixed system. It was the erosion of the employer-based system that led to Obamacare.
Sanders and his 15 Senate co-sponsors propose to eliminate the employer-based system entirely. He would gradually expand Medicare to cover everyone over four years.
The legislation is silent on how to transfer the $1.1 trillion spent by employers on health insurance to government coffers, necessary to defray the cost of his plan. He doesn't address how he would counter the tremendous opposition that disrupting the existing system would draw from employers and their workers, including those in many unions.
Sanders decries the lack of progressive think tanks to come up with answers to those and other transition questions. But the problem isn't the absence of good ideas. It's the absence of fertile soil in which those ideas can grow.
That will change rapidly if Republicans succeed in repealing Obamacare, or undermine it and send the uninsured rate soaring again. That, and only that, will turn the single-payer threat into the last viable path to universal coverage.
An edited version of this story can also be found in Modern Healthcare's Oct. 2 print edition.
