For proponents of a single-payer health-care system, there were few arguments in its favor more compelling than the virtual ubiquity of state-funded health-insurance regimes across the industrialized world. Those advocates dismissed the idea that the unique conditions that prevail in the U.S. render such a system politically untenable, stressing the moral duty on Americans to expand insurance coverage over impediments like cost and feasibility. Those advocates have since received a real-world education in what Americans are prepared to accept from their health care system, and it’s not Medicare-for-all.

Elizabeth Warren is only the latest erstwhile advocate of a virtual state-run health-insurance monopoly to abandon the proposal. She will surely deny that she has backtracked at all, but her behavior suggests otherwise. At an appearance on the campaign trail over the weekend, Sen. Warren introduced a new word into her pitch for health-care reform: “choice.”

“Millions more Americans will have the choice to ditch their private insurance and enter a high-quality public plan,” Warren told a roomful of supporters. She emphasized that the transition to Medicare-for-all would become the most popular reform option “when you’ve had the choice,” adding cautiously, “nobody has to, but when you’ve had the choice.”

There’s a reason why most Medicare-for-all proposals virtually nationalize the health-insurance industry by prohibiting employer-sponsored health insurance, and it’s not just because its Democratic sponsors have a particular antipathy toward that $900 billion-per-year industry. To the extent it’s possible, the consolidation of the private health insurance industry into public hands makes Medicare-for-all’s math work.

Medicare-for-all’s “savings” are a by-product of compelling hospitals, doctors, and care providers to accept reimbursements well below what they receive from Medicare patients, and that is only possible with a monopoly control on the disbursement mechanisms. Moreover, downsizing the number of insurers with which those providers must negotiate to just one allows for the streamlining of the compliance and negotiation process, to say nothing of the reduced administrative paperwork. At least, that’s how it all makes sense on paper.

In the real world, though, the obstacle presented by the number of Americans with private insurance who are satisfied both with the quality of care and cost associated with their plans has proven insurmountable. Warren is only the latest to acknowledge that reality. Kamala Harris was the first.

“Let’s eliminate all of that,” the California senator said with a laugh when asked about her co-sponsorship of the Sanders bill and its plan to prohibit employer-backed health insurance. “Let’s move on.” But the scale of the backlash to Harris’s acknowledgment of one of the plan’s key provisions shocked even her fellow Democrats. Sens. Tim Kaine, Gary Peters, Dick Durbin, and Dianne Feinstein dismissed the idea of forcing approximately 150 million Americans and their dependents into a government-run insurance monopoly. Even Sen. Cory Booker, himself a presidential candidate and another co-sponsor of Sanders’s bill, retracted his support. “Even countries that have vast access to publicly offered health care still have private health care,” Booker said when asked if he still supported eliminating private insurance. “So, no.” Harris eventually relented. Under pressure, her campaign confessed that the senator was amenable to health-care-reform plans that stop short of Medicare-for-all.

Some Democratic candidates in the race for the White House, like former South Bend Mayor Pete Buttigieg, claim they underwent a conversion once they learned that such a plan entailed getting rid of the private health-insurance industry. Others continue to insist that Americans can have it all. “I support Medicare-for-all,” said former Housing and Urban Development Sec. Julian Castro, “with a role for private insurance for individuals that choose it.” What he is describing then isn’t a single-payer system but something more like a public option—which, by the way, is what progressives have derided as a half-measure when candidates like Joe Biden advance it. But, with Warren’s retreat, Biden’s proposal has become the default position for all of the 2020 Democratic candidates now save one: Bernie Sanders.

Sanders has not abandoned his own bill, nor has he backed off his intention to impose a bigger tax burden on the American middle-class to partially fund this dramatic expansion of government. And since Sanders is the last self-described socialist in town, he’s gradually reclaiming the progressive vote he had lost a portion of to Warren. But it’s clear now that his support for Medicare-for-all is not predicated on the notion that such a proposal would be broadly popular and less politically fraught than pledging to preserve the status quo. The days in which that talking point prevailed are long gone. Sanders and his fanbase may not acknowledge it, but the public-relations fight over a single-payer system is essentially over. Its advocates lost.

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