The Democratic debate further revealed the political minefield that is single payer

Democratic presidential hopefuls participate in the second round of the first primary debate of the 2020 campaign season at the Adrienne Arsht Center for the Performing Arts in Miami.
(Saul Loeb/Getty Images)
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The Affordable Care Act would not have made it through Congress had Democrats not conceded to Republicans on two polarizing points: No federal taxpayer dollars could be spent either on abortions or on insurance for immigrants living in the country illegally.

On a debate stage occupied only by would-be Democratic presidential candidates, however, no such concessions were in the offing. And yet, those issues represent two of the biggest political hurdles in the path to a single-payer healthcare system.

When asked Thursday night to raise their hands if their plan for expanding government-provided health insurance “would provide coverage for undocumented immigrants,” all 10 candidates did (although former Vice President Joe Biden raised his so tentatively that moderator Savannah Guthrie thought he had not).


“This is not about a handout. This is an insurance program,” South Bend, Ind., Mayor Pete Buttigieg explained, eliding the fact that the coverage at issue, unlike an auto insurance plan from State Farm, would be heavily subsidized. “And we do ourselves no favors by having 11 million undocumented people in our country be unable to access healthcare.”

That’s a good argument. Another one is that leaving millions of people outside the federal insurance umbrella forces doctors and hospitals to retain at least some of the billing and collection infrastructure that adds costs to and reduces the efficiency of the system.

But as Rep. Joe “You Lie!” Wilson (R-S.C.) would attest, the moral and economic arguments in favor of covering the undocumented aren’t persuasive to a large number of Americans. President Trump — an astute reader of the political winds — knows this too; his only tweet during Thursday’s debate mocked the candidates for taking this stance.

Several of the 20 candidates in the debates — most notably Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.) and former San Antonio Mayor Julian Castro — also pledged to include coverage for abortion in their government-run insurance plans. Said Sanders, “It didn’t come up here, but let’s face this, Medicare for All guarantees every woman in this country the right to have an abortion if she wants it.”

Castro framed the issue as one of “reproductive justice,” adding, “What that means is that just because a woman — or let’s also not forget someone in the trans community, a trans female — is poor, doesn’t mean they shouldn’t have the right to exercise that right to choose. And so I absolutely would cover the right to have an abortion.”


I can pretty much guarantee that Castro won’t be able to do that. Even when Democrats and independent allies controlled the House and held a filibuster-proof supermajority in the Senate in 2009, they could not overcome opposition from Republicans and members of their own caucus to the idea of using federal tax dollars to pay for abortions — or provide subsidies for insurance policies that covered the procedure. Instead, they had to settle for a tortuous compromise offered by then-Rep. Bart Stupak (D-Mich.) that required insurers to administratively separate abortion coverage from the rest of the policy and fund it with non-federal dollars.

(Republicans never liked that approach, nor did Stupak’s constituents, who ousted him in 2010.)

Granted, the Democratic Party doesn’t send many folks, if any, to Congress these days who don’t support abortion rights. But the party would still have to hold a filibuster-proof majority in the Senate and be willing to defy the polls that show most members of the public do not think tax dollars should be spent on abortion. Yes, there are polls pointing the other way too, but even if the percentage of Americans opposing such spending has shrunk, the number is still in the tens of millions.

One issue that did get batted around was whether people could keep their current insurance plans under a single-payer system. That’s a divisive question, as many Americans have told pollsters that they’re alarmed by the prospect of losing their current health plan — even if they aren’t completely satisfied with that plan. As former Rep. John Delaney (D-Md.) noted, “One hundred million Americans say they like their private health insurance…. I think we should be the party that keeps what’s working and fixes what’s broken.”

Delaney is also right about the financial problems that could be caused by switching all providers to Medicare, which has historically underpaid for services. But that’s a surmountable problem. Keeping multiple insurers in place alongside a federal program, on the other hand, would defeat one of the main purposes of moving to single payer, which is to slash the outsize administrative costs (and hassles and uncertainties) of the current system.

Oh and yes, there is the price tag. None of the candidates talked about how much their plan would cost, and only a handful alluded to the tax increases they would support to pay for their expansive visions of government. I know, I know — advocates of single payer will argue that the move will lower total healthcare spending. But it will raise the federal government’s share, and that’s a potentially insurmountable hurdle as well.


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