The stunning failure of Republicans to repeal and replace Obamacare has left many supporters of single-payer feeling like the wind is at their backs. After all, not only did Republicans fail to make a dent in Obamacare, they were actually emerging as guardians of Medicaid. The idea that government has a role in making sure individuals have coverage, it seems, has taken hold in both parties. But looked at another way, the GOP failure actually shows what an uphill battle it would be for Democrats to pass single-payer healthcare.
At the outset I should say that if you haven't read Peter Suderman's piece at Reason as to why limited government advocates should take the threat of single-payer seriously, you should do so. He points to the growing momentum among liberals to pass single-payer and notes that they're starting to grapple with some of the very real issues posed by turning it into reality. He sees parallels to how liberals regrouped after the failure to pass a national healthcare plan under President Clinton while Republicans slept, and thus laid the groundwork for the eventual passage of Obamacare. Opponents of government-run healthcare should heed all his warnings.
But at the same time, liberals salivating over debates about the merits of the Beveridge vs. Bismark single-payer models shouldn't get too cocky, either.
Though, viewed one way, the GOP failure to repeal and replace could be seen as evidence of renewed public acceptance of a government role in healthcare, on the flip side, it could be viewed as an affirmation of the power of the status quo bias that has traditionally doomed any major overhaul of the U.S. healthcare system.
For decades, Democrats had tried and failed to pass some sort of national healthcare plan, and the biggest obstacle had always been Americans' fears that it would disrupt their current coverage. It was why the Clinton effort went down in flames. It was the central reason why Barack Obama abandoned the idea of single-payer. And it was why he made his infamous promise about people getting to keep their doctors and plans if they liked them.
By the time Republicans had the power to do anything, Obamacare had become the new status quo in healthcare and tinkering with it would have implications for the health coverage of millions of Americans. Suddenly, it was Republicans who looked like they were engaging in a radical plan of social engineering, while Democrats were sounding reasonable by suggesting they'd be open to more modest changes.
We can talk about what liberal activists can do to get Democrats to embrace the idea of single-payer healthcare. But remember that conservatives got an entire party to embrace the idea of repealing and replacing Obamacare – getting presidential candidates, House and Senate candidates, gubernatorial contenders, and even those running for state legislature to promise to fight Obamacare. Repeal and replace was a central promise of the party, from the top down, for over seven years. And yet, the status quo bias was too powerful to hold them to their promises. Even six Republican senators, who voted for a repeal bill in 2015 when Obama was in office to veto it, ended up voting "no" on the same bill this time around now that it would actually have consequences.
While, if passed, the Republican bill would have affected millions on Medicaid and on the individual market, any true single-payer bill would have to impact the employer-based healthcare system, which covers 49 percent of the country, or 156 million people, according to the Kaiser Family Foundation. Any proposal that tries to expand Medicare to all will have the additional task of convincing seniors – a reliable voting block, especially in congressional elections – that it won't affect their care. Creating a Medicaid buy-in would involve trying to figure out how you're going to get doctors and hospitals to accept rock bottom payment rates for tens of millions more people if you want to keep any control over the cost of the program.
This doesn't even get into the massive tax increases required to support a single-payer system. An analysis of the Bernie Sanders single-payer plan from the liberal Urban Institute projected that it would cost $32 trillion over a decade. To put it in context, that's more than the U.S. is projected to spend on Medicare, Medicaid, Social Security, and Obamacare over the next decade, according to the Congressional Budget Office. It is about 35 times the price tag of "around $900 billion" that Obama used to sell Obamacare. Even a significantly scaled-back version of such a plan would involve massive tax increases, including on the middle class.
And remember, liberals don't have to just convince Democratic leadership to get behind single-payer, they have to convince the least liberal Democratic Senators. The current Senate is arguably, on average, the most conservative ever. But as the failed Obamacare repeal drive reminded us, any small group of more centrist members can tank legislation, and individual interests of some members can be more powerful than what the party wants. And in the case of repeal, this was true even though Republicans were looking for 50 votes rather than 60.
For Democrats to retake the majority, they are going to have to win seats in states that typically vote Republican. Even their current 48-vote minority includes seats in Missouri, Indiana, North Dakota, and West Virginia – states that President Trump won by a range of 19 to 42 points. So, ultimately, achieving single-payer won't be about getting Sens. Bernie Sanders and Chuck Schumer on the same page, it will be accomplishing that, and then getting the Sen. Joe Manchins of the world onboard.
This doesn't mean that conservatives should rest easy and assume the single-payer threat is over. It doesn't mean liberals can't achieve smaller victories that, over time, could move the system closer and closer toward something akin to single-payer. All I'm saying is, after witnessing the collapse of one party's seven year-pledge on healthcare, the lesson we take from it maybe shouldn't be that the public is primed for another major political battle to radically overhaul the system in a way that could disrupt the coverage of hundreds of millions of people.