Obamacare is still with us. The latest Republican repeal effort has failed, and the enrollment period begins Nov. 1. A bipartisan Senate bill to address its problems could be voted on sometime this fall. Meanwhile, many Democrats are embracing a single-payer "Medicare for all" system as the next step in healthcare reform. But making single-payer the top priority now could jeopardize the gains made since passage of the Affordable Care Act, which is still being sabotaged by the Trump administration.
Since FDR, Democrats across the political spectrum have supported guaranteed coverage for all Americans, regardless of their health status or ability to pay. They enacted government-payer systems that protected specific populations — Medicare, Medicaid and the Children's Health Insurance Program. The Affordable Care Act, starting in 2014, covered many others who were left behind by those programs.
To pass the ACA, Democrats from the center to the left checked their ideology and cooperated to achieve gains that improved people's lives and were politically attainable. Americans who rely on public funding for their healthcare need that kind of spirit again.
Thanks to the unpopular Republican alternatives, Obamacare has never had stronger public support. However, if fixes are not made soon, premiums will rise and the state and federal exchanges may fail, feeding the Republican storyline that government cannot manage healthcare. Advocates for universal coverage must vigorously combat the Trump administration's efforts to undermine the law while working with Republicans who are willing to protect Medicaid and stabilize the individual market.
If the ACA is sustained, single-payer becomes more viable. With Obamacare in place and functioning, the number of uninsured will continue to fall. Preserving the healthcare funding the ACA mandates would help make a transition to a universal system less costly and less disruptive. When Obamacare works, it gives people confidence that government can solve problems, an outcome that strengthens progressive priorities on many other issues as well.
Conversely, the political track record of attempting to enact major changes to the healthcare system in one grand bill — as with the California and the national single-payer proposals — is likely only to produce a dismal political result for Democrats.
The ACA is itself a case in point. When it disrupted coverage for the small number of Americans who buy insurance on their own, the Democratic Party lost large majorities in both houses of Congress. In 1994, following President Clinton's high-profile failure to enact a universal coverage plan, Republicans gained control of the House and Senate for the first time in 40 years. I was a White House political affairs staffer in the Clinton administration; I worked on this issue and experienced the electoral devastation first-hand.
President Trump famously asked, "Who knew healthcare could be so complicated?" Now Democrats rushing to endorse single-payer seem to believe that healthcare can be "un-complicated": Coverage for all, no co-payments or deductibles, and every doctor in your network.
Failure to address the details in California (where a single-payer bill was shelved in June) and in Sen. Bernie Sanders' national plan render "Medicare for all" more a slogan in the vein of "repeal and replace" than a serious, politically viable remedy for the healthcare system.
To move single-payer forward, advocates must make hard choices about what services will not be covered and who will pay the multitrillion-dollar cost. On the front end, they must persuade 160 million people with good employer coverage to embrace a government plan. If Democrats don't fill in those details, their Republican opponents will, in ways that will harm the proposal's credibility.
Democrats have an enormous opportunity for political gains in 2018 and 2020; but winning in those years requires prevailing in moderate, even conservative areas. Endorsement of an ill-defined single-payer proposal will not help. And if support for "Medicare for all" becomes a litmus test for Democratic presidential candidates, it might be a winning strategy in the primaries but not in the general election
There will be no chance of achieving affordable coverage for every American through single-payer or any other plan unless Democrats control Congress and the presidency in 2021. Even then, single-payer would still be a long way off, but it would at least be in the realm of possibility, along with a wider progressive agenda. That's what Democrats should be fighting for.
Tom Epstein worked on healthcare policy and politics for the California Department of Insurance, the Clinton administration and as vice president for public affairs for Blue Shield of California.