Commentary Magazine


The Move to Single-Payer Health Care

Do voters exist? In the United States, that is–do we still have voters? All available evidence points to yes, we have millions upon millions of them who vote in national elections. But maybe I’m getting too caught up in the numbers. Recent anecdotal evidence challenges my theory. I’m referring, of course, to the obvious consequences if the Supreme Court strikes down Obamacare. The result, everyone says, will be single-payer, government-run health care for all.

The problem, though, is that this was suggested and polled repeatedly during the health care debates in 2009-10. As the debates dragged on, a single-payer health care program repeatedly polled as the least popular path to universal coverage, and its poll numbers dropped over time. So I’ll pose a simple question: If the entire Obamacare law is struck down, will President Obama campaign on a single-payer system? No, he won’t. And the reason is because it will hurt him with voters, who in the end really do exist. Ezra Klein has, however, proposed a feasible way for the Democrats to move toward a default single-payer system:

I think that path would look something like this: With health-care reform either repealed or overturned, both Democrats and Republicans shy away from proposing any big changes to the health-care system for the next decade or so. But with continued increases in the cost of health insurance and a steady erosion in employer-based coverage, Democrats begin dipping their toes in the water with a strategy based around incremental expansions of Medicare, Medicaid, and the Children’s Health Insurance Program. They move these policies through budget reconciliation, where they can be passed with 51 votes in the Senate, and, over time, this leads to more and more Americans being covered through public insurance. Eventually, we end up with something close to a single-payer system, as a majority of Americans — and particularly a majority of Americans who have significant health risks — are covered by the government.

It certainly could happen. Klein isn’t in love with the idea, to say the least. But yes, it’s a possibility. But the part I take issue with is the first sentence, in which Klein says everybody walks away from the health insurance issue for a decade. I don’t think Obama would do that, and I don’t think the election could pass by without health care thrust right back in the debate, only this time centered on the question of how to replace Obamacare.

So in that case, politically, what does Obama do? Like I said, I don’t think he runs as an advocate for single-payer. Klein’s suggestion is probably workable in the long run, but Obama can’t run on it. He cannot stage a re-election campaign on the idea that he’ll give up the reform game and that it’s now up to Harry Reid to slowly and quietly bring us to the cusp of single-payer while everyone else is distracted watching “Mad Men” and arguing over Tim Tebow.

Again, I don’t doubt the feasibility of this incremental Medicare-for-all approach. But elections include voters, and voters will want to know what the candidates are going to do about health care if Obamacare disappears entirely. The president cannot say “nothing.” He cannot say “trust us, we’ll take care of it in a way that requires no public discussion and no voter input.” And he cannot say: “We’ll do what Canada and Britain have done.” So what will he say?