AFP Photo/Jewel Samad
Opinion writer

While Hillary Clinton and Bernie Sanders started their presidential campaigns with an unspoken mutual non-aggression pact, it was inevitable that as the voting approached and the sense of urgency grew, they would start criticizing each other more and more. Intra-party criticisms are always revealing, since they show where the fault lines within the party might be, and their success or failure demonstrates what partisans are thinking.

But an attack Clinton has now launched on Sanders’ support of single-payer health care is both odd and important, so I’m going to try to sort it out — both the substance and the politics.

Let’s cover the policy question first. While Clinton wants to build on the reforms of the Affordable Care Act, Sanders supports single-payer insurance, which would mean scrapping our current system and remaking it along the lines of one of the variations of health insurance we see in every other industrialized country. It’s sometimes called “Medicare for all.” But it could be anything from a purely socialized plan like they have in Great Britain, where both insurance and health care itself are largely owned and operated by the government (not likely), to one of the hybrid systems in place somewhere like France, where there’s a basic government plan that covers everyone, then most people buy supplemental private insurance that gives them whatever extra benefits they want (which is somewhat analogous to Medicare and supplemental Medigap plans).

In the past, Clinton has said a single-payer plan would be too expensive. Sanders replies that it would actually save us money, since every single-payer plan in existence spends less than our current system, and the extra taxes it would require would be more than offset by what everyone would save by not having to pay insurance premiums. But Clinton has now offered a new argument: that Sanders would leave Americans’ health care vulnerable to Republican governors who would try to undermine it in the same way that they have the ACA:

Speaking at an event in Iowa, Clinton pointedly contrasted her health-care plan with Sanders’s, claiming that his proposal would turn over health insurance to Republican governors.

“His plan would take Medicare and Medicaid and the Children’s Health Insurance Program and the Affordable Care Act health-care insurance and private employer health insurance and he would take that all together and send health insurance to the states, turning over your and my health insurance to governors,” Clinton said, naming the state’s Republican Gov. Terry Branstad. “I don’t believe number one we should be starting over. We had enough of a fight to get to the Affordable Care Act. So I don’t want to rip it up and start over.”

Clinton called Sanders’s plan a “risky deal.” …

Sanders spokesman Michael Briggs said  that while Sanders advocates a single-payer system, he has not developed legislation as a presidential candidate to implement it. Under a 2013 single-payer bill introduced by Sanders, Briggs said, it was “national legislation for all our states.”

“Secretary Clinton is inaccurate in suggesting that Republican governors would be able to circumvent the law and deny implementation in their states,” Briggs said.

So who’s right about this? To a degree, they both are.

First, it’s true that Sanders hasn’t yet released a health care plan during the campaign. But until he does, it seems fair to examine what he has introduced in the past. When the debate over the ACA was ongoing, Sanders offered up a substitution for it that would create a single-payer plan instead. It didn’t go anywhere, but he subsequently reintroduced it, the last time in December 2013 in this version. And it does indeed eliminate Medicare, Medicaid, CHIP, and other programs, to replace them with a single plan, which is the whole point — one system for everybody.

And  yes, it’s a state-based plan. To wit:

Sec. 101. Establishment of a State-based American Health Security Program

(a) In general. —

There is hereby established in the United States a State-based American Health Security Program to be administered by the individual States in accordance with Federal standards specified in, or established under, this Act.

Is that case closed? Well, yes and no. Yes, this is a state-based plan. But Sanders would argue that it also establishes clear standards and procedures that would make it impossible for a Republican governor to undermine it. And it’s important to keep in mind that when it came to the ACA, the primary way Republican governors have been able to screw over their constituents has been on the question of Medicaid eligibility.

When the Supreme Court ruled that states didn’t have to accept the expansion of Medicaid, that allowed Republican states, most of whom had lower cutoffs for eligibility than the 133 percent of the poverty level written into the ACA, to refuse the expansion and leave their working poor citizens without coverage. Millions of people have gone without insurance because of this, but it’s confined to the Medicaid question. Republicans tried and failed to take coverage away from the next income category up — people earning more than 133 percent of the poverty level, but little enough that they receive subsidies to buy insurance through the ACA exchanges. The Supreme Court said they couldn’t do that. And yes, many states refused to set up their own state exchanges, which was a problem when the federal exchange worked so poorly at the start (though it’s working fine now).

But if you step back and look at what the states have been able to do to undermine the ACA, it really comes down to Medicaid expansion. As much human misery as the governors’ despicable actions may have caused, it all runs through that one program. Given the way the Sanders plan is written, it doesn’t seem that they’d be able to deny their own citizens coverage or restrict it in some substantial way. Does that mean that if Sanders’ bill became law, an unusually creative Republican governor couldn’t find some way to undermine it and deprive his constituents of coverage or benefits? Maybe, maybe not; it’s hard to predict.

So it seems that Clinton is making a legitimate criticism of Sanders’ bill. Yet Sanders’ counter-arguments are also perfectly reasonable. (If Sanders wants to argue that this bill doesn’t reflect his current thinking on the topic, that’s fine, but if so he should explain exactly what he’d change.)

In any case, the basic divide between the two is that Sanders wants to remake the health insurance system, while Clinton wants to build incrementally on the ACA. But in the context of a Democratic primary, her attack on single-payer insurance is a little strange.

On the broadest level, there are two basic classes of arguments one could make against a plan like single-payer. The first is that whatever its merits, it just isn’t feasible from either a practical or political standpoint. This is the position Barack Obama took when he was advocating for passage of the Affordable Care Act. “If I were starting a system from scratch, then I think that the idea of moving towards a single-payer system could very well make sense,” he would say in 2009 when asked by liberals about it. “The only problem is that we’re not starting from scratch.” He was talking about the disruption to the health care system it would cause, but there was also a political reality at work, namely that the chances of successfully getting a single-payer plan through Congress were essentially zero (just look at what it took to get a market-based plan like the ACA through, and it made it by the skin of its teeth).

While there are certainly liberals who disagree with this line of thinking, nobody would be surprised, insulted, or appalled if Hillary Clinton adopted it. If she said, “Look, single-payer might be a good idea, but it’s just not realistic at this point in history, so let’s focus on what we can accomplish in the next few years,” it wouldn’t be controversial and it wouldn’t drive away any Democrats who weren’t already firmly in Sanders’ camp.

But that’s not her argument. She’s making a second kind of argument, that single-payer is itself a bad idea — not that we might like to do it but we can’t, but that it fails on the merits.

To oversimplify a bit, the first argument is one you make to Democrats, and the second argument is one you make to Republicans, and maybe to independents. But we’re in the middle of a primary.

And single-payer is a hugely popular idea among Democrats. Depending on how you phrase the question, you can see support as high as 80 percent or more. To take just one recent example, a Kaiser Health Tracking poll from December asked whether respondents favored “having a national health plan in which all Americans would get their insurance through an expanded, universal form of Medicare-for all.” Eighty-one percent of Democrats said they favored it, with 52 percent favoring it strongly.

So why would Clinton be attacking single-payer in the way she is — on the cost issue before, and now on this state issue — when there’s a less risky way to frame her objections to Sanders’ idea? Maybe she sincerely thinks that single-payer would be disastrous, though I have trouble believing that — she’s enough of a policy wonk (particularly on this issue) to understand how well it works in so many countries. Maybe she’s horrified by how many people have been denied Medicaid, and thinks that any plan that allows Republican governors to make mischief is a terrible mistake (though if that were the case, she could argue that a different single-payer plan might be acceptable, just not the one Sanders proposed). Or maybe she wants to signal to general election voters that while she’s been staking out liberal positions on lots of issues, she’s no crazy lefty.

I can’t say what the answer is. But if Clinton and Sanders keep arguing about this issue, eventually we may be able to figure it out.

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UPDATE: The Sanders campaign offers a reply to the question of whether Republican governors would be able to undermine his 2013 single-payer plan, with this statement:

“If a state submits a plan that does not meet requirements, or if it refuses to participate in the program, then the bill allows the federal government to step in and do it for them, preventing Republican governors from offering subpar programs or refusing to provide health coverage for their residents.”

The Sanders camp argues that this resembles the ACA exchanges, where the federal government is now doing the job that some states refuse to do, much more than the Medicaid expansion, where states successfully kept people from getting insurance.