One of the most important political trends of the last couple of decades is what is often referred to as “asymmetric polarization,” which means that while Democrats were getting more liberal, Republicans were getting much, much more conservative.
That trend, however, may be entering a new phase. In many policy areas, it’s almost impossible for the GOP to get any more conservative than it has become, while Democrats are continuing to move left.
Nowhere is this clearer than on health care. The experience of the last decade — the passage of the Affordable Care Act, the political challenges of its implementation, and the failed Republican effort to repeal it and replace it with a spectacularly unpopular plan moving government out of the business of helping people get coverage — has brought about a new boldness among Democrats. While some of us have been predicting for a few months that support for some version of single-payer health care would gradually become the default position for those seeking the 2020 presidential nomination — and thus for the party as a whole — it’s happening faster than one might have thought.
A bunch of potential candidates, including Cory Booker, Kirsten Gillibrand, Elizabeth Warren, and Kamala Harris, have moved from their previous position — a somewhat vague support of single payer in the abstract — to becoming co-sponsors of Bernie Sanders’s single-payer bill, which is set to be released this week. Today Sen. Tammy Baldwin of Wisconsin, who’s up for reelection next year, added her name to the list, and so did Sen. Richard Blumenthal of Connecticut and Mazie Hirono of Hawaii, joining a number of others. A single-payer bill in the House is co-sponsored by more than half the Democratic caucus (though House Minority Leader Nancy Pelosi of California is notably holding off).
This is a significant change in Democratic Party orthodoxy. Can it help Democrats politically? The answer is yes, it can — but it’s complicated.
For starters, it would be better if we referred not to “single payer” but to “universal coverage,” since the latter is the real goal, while the former is just one way to achieve that goal (see Harold Pollack for more on this). One big question about Sanders’s plan is whether it will be the kind of “Medicare for all” he’s advocated in the past, or something like “Medicare for all who want it,” which would retain a role for private insurance. There are multiple paths to universal coverage, and no one who is serious about the complex policy questions involved believes that a true single-payer plan is the only way to get a system that does what we want it to. But that reality may be powerless in the face of the fact that “single payer” is a slogan that people are already rallying around.
In any case, the first thing Democrats have to acknowledge is that if this is going to be their goal, they have a challenging persuasion task ahead of them. Most voters don’t really understand what single payer is and haven’t thought much about it, mostly because it’s only now emerging as a topic of mainstream debate. That makes public opinion on the question extremely fluid. Polls tell us something about how receptive the public might be to a single-payer plan, but they also demonstrate that they can be easily swayed in either direction.
Take, for instance, this Kaiser Family Foundation poll from July. It found 53 percent of respondents saying they’d support “a national health plan, or a single payer plan, in which all Americans would get their insurance from a single government plan.” That’s quite encouraging to liberals, but when they offered some reasons one might oppose it (it would give government too much control, it would require new taxes), support dropped to as low as 34 percent. On the other hand, when they offered reasons to support single payer (it would guarantee universal coverage, it would save administrative costs), support climbed as high as 72 percent.
That tells us that it’s impossible to know for sure how a debate over single payer will turn out. One thing we can say, however, is that Democrats probably don’t need to be too paralyzed by fear of the inevitable Republican charge that it would represent big government controlling your life. As Republicans discovered when they tried to kick millions of people off Medicaid and undermine the program, the American public is perfectly fine with the government helping to give people health coverage. Medicare and Medicaid are both extremely popular with their recipients, who in total now number about 130 million.
That doesn’t mean the public isn’t still receptive to arguments about big government. But it does mean they can be refuted. Nevertheless, there are other arguments Republicans will make in opposition that could be persuasive, including that a single-payer plan would require a big tax increase, and that it would disrupt the system in ways that might leave some people worse off even if many more people benefit. Democrats should invest time and resources in figuring out the best way to counter those arguments, especially since we know all too well how much people fear change when it comes to their health care.
But single payer offers Democrats something extremely powerful: an ambitious policy change that will motivate their own voters to haul themselves to the polls. Saying that the other side is terrible is important and often true (particularly right now), but experience has shown that if you want to really get your voters to the polls, at least in presidential elections, they have to have an affirmative reason to get excited. That comes from the personality of the candidate, but it also comes from their vision of change. Whether they were right or not, in 2016 Democrats didn’t perceive Hillary Clinton as offering a sweeping policy agenda; she seemed more interested in tinkering with every program to make it work better. Even if that’s a big part of what was needed, it doesn’t make for a stirring campaign.
That gets to an important thing that a big goal like universal coverage can accomplish for Democrats, who are often accused of being too focused on small-bore policy change. It sends a message to voters that goes beyond health care, saying something about who Democrats are, what’s important to them, and what their vision of the future is. It says that they want to deploy government to solve problems and improve people’s lives, stepping in where the free market has failed to remove uncertainty and create conditions for everyone to thrive. And it establishes a clear contrast with the status quo.
Democrats need to keep in mind that they’re setting out on a long road. Even if they’re ultimately successful and we achieve universal health coverage in America, getting there will take years and the debate will have many ups and downs. It’s good to see them rallying around an ambitious idea for positive change. But achieving it is going to require all the skill and persistence they can muster.