When Hillary Clinton was working on healthcare reform as first lady more than two decades ago, she disappointed some left-wing Democrats by refusing to push a system that would offer government health coverage to all Americans.
Instead, like many top Democrats and liberal leaders, Clinton advocated a centrist approach that would guarantee health coverage while preserving the current system of commercial insurance. That political strategy later became the foundation of President Obama’s successful push to enact the Affordable Care Act.
Now, Clinton finds herself replaying some of the same battles over how to achieve universal healthcare as she runs for president and tries to beat back a challenge for the Democratic nomination from Vermont Sen. Bernie Sanders.
Sanders, a self-described democratic socialist, is exciting liberal activists by championing a proposal where the government supplies healthcare in what’s known as a single-payer system, an elusive ideal that many on the left have demanded for more than half a century.
Clinton argues that Obama’s hard-fought healthcare law, often called Obamacare, should be defended and improved. She has called for new consumer protections to lower the cost of prescription drugs and safeguard patients from surprise medical bills and limited insurance networks.
The divergent views epitomize the differences between the candidates – Clinton as a battle-hardened realist, with Sanders the uncompromising crusader – and the healthcare debate has become one of the most rancorous parts of an increasingly competitive primary. Polls show Sanders closing the gap with Clinton in Iowa and leading her in New Hampshire, the states that hold the country’s first two nominating contests.
Sanders, who has repeatedly introduced single-payer legislation in his 2 1/2 decades in Congress, wants to use new taxes to expand Medicare to everyone. He says it would save patients money by reducing insurance premiums.
“We can do better. We must do better,” Sanders said at a candidate forum in Las Vegas last week.
The Clinton campaign has fired back. Clinton’s daughter, Chelsea, claimed during a campaign stop in New Hampshire this week that Sanders would “dismantle Obamacare” and “strip millions and millions and millions of people off their health insurance.” The Sanders campaign rejected the charge, saying its plan would expand coverage.
Clinton has also called Sanders’ proposal financially unrealistic, arguing that it would require raising taxes on the middle class.
And her campaign criticized the senator for potentially delaying details on how he wants to fund the plan until after the Iowa caucuses on Feb. 1, which would backtrack on an earlier pledge.
Sanders wants to “basically start all over again, start a contentious debate to try to get to a single-payer system,” Clinton told MSNBC’s Rachel Maddow on Thursday. “But he’s not telling us what it will look like and what it will cost.”
After some mixed signals from his campaign, Sanders said Thursday that he would provide new information before the caucuses.
This intra-party battle over single-payer healthcare dates back decades, as many Democrats have long hoped the federal government would assume responsibility for providing health insurance for all Americans, just as Medicare now covers the elderly.
But after years of failed efforts to provide “Medicare for all,” as the idea has been called, many Democrats – including liberal lions such as former Sen. Edward M. Kennedy (D-Mass) – concluded they would have to compromise first if they were ever to get to universal coverage.
“Even President Obama said he would support a single-payer system, if he could do anything he wanted,” former Rep. Henry A. Waxman (D-Los Angeles), a liberal Democrat who helped craft the Affordable Care Act, said in an interview Thursday. “But he and we chose a moderate alternative that we felt would accomplish the goals of getting people insurance coverage. And even this more moderate approach was extremely hard to pass."
Five years after its passage, the health law has expanded coverage to some 17 million Americans. But millions more remain uninsured. And for many consumers, the law has not yet delivered on Obama’s promise to lighten the burden of healthcare costs.
That has helped create an opening for Sanders, who has been able to use his presidential campaign to thrust single-payer back into the national conversation at a time when he’s gaining in polls.
“Liberal supporters feel he might actually have a chance,” said Robert Blendon, a Harvard University professor who studies healthcare and public opinion. “He’s saying to them, 'I have an issue you’ve always cared about.’”
Single-payer systems can take different forms. In Canada, the government provides insurance but pays private medical providers for healthcare, much as Medicare does in this country. In Britain’s National Health Service, the government not only provides insurance but also employs doctors and owns hospitals.
These systems can be more affordable because their administrative costs are often lower than those of commercial insurers. But political opposition in the U.S. to any form of single-payer coverage has remained strong from the healthcare industry and from conservatives wary of more government involvement in medical care.
When work began on the Affordable Care Act in 2009, neither Obama nor any senior Democrats on Capitol Hill proposed a single-payer system. “It never would have passed,” Waxman said.
Still, some Democrats held out hope that the law could at least advance the cause. Early versions of the legislation included a provision to create a new government health plan, known as the public option, to compete with private insurers. Another version proposed to expand Medicare eligibility by allowing Americans as young as 55 to enroll.
Both proposals were bitterly opposed by insurers and other industry groups, as well as by many centrist Democrats, all of whom were needed to pass the legislation. The ideas were dropped.
Clinton does not seem interested in reopening the issue.
“Now is not the moment to plunge the country back into a divisive battle,” said Jake Sullivan, one of her senior advisors.
After all, in the end, Blendon said, “Voters tend to go for the middle road.”