Though it has failed to excite the national political press, Democrats are attempting to transform the 2018 midterms into a referendum on the state of health care in America. According to one study, over half of the ads Democratic candidates fielded in 2018 mentioned healthcare—a rate that outpaces every federal election in the last ten years. Republicans, too, have focused on health care more than at any point since the 2010 midterms. By contending that only the GOP can be trusted to preserve Affordable Care Act-related protections for people with pre-existing conditions, even Donald Trump has revealed how much the issue of healthcare is moving the needle.
Democrats have it right. Health care is their issue. Public opinion surveys consistently find that Democrats are trusted on the issue more than the GOP, that health insurance premiums are an increasing strain on household budgets, and that Obamacare is popular.
Obamacare’s political fortunes seem to have an inverse relationship with those of the GOP. Almost the minute that Republicans took the White House, voters discovered a lot to like in Barack Obama’s sweeping health-care reform law. The law hadn’t changed, but the prospect of its repeal suddenly became quite real. In the end, after some serious attempts at repeal, the GOP could only manage to rescind the law’s most unpopular element: the individual mandate to purchase insurance. The individual mandate joined the law’s other unpopular funding mechanisms, including the directive for small-sized employers to provide health insurance and the so-called “Cadillac tax,” on the ash heap, leaving only the law’s most popular (and expensive) elements.
There are lessons for Democrats if they should suffer the GOP’s fate and manage to catch the bus.
As Sen. Chuck Schumer has said, when it comes to health care, “all options” are on the table. But by all options, he meant anything related to expanding public-sector control over the health insurance market. Among the experiments the Senate minority leader found enticing were expanding access to Medicare, expanding access to Medicaid, creating a “buy-in” for both programs, and, of course, a single-payer system in which every American is forced into a government-backed health-insurance monopoly. That seems to be the model favored by most Democratic candidates for federal office. There’s just one problem: You can’t call it single-payer.
In about half of the House races in which a Democratic candidate is on the ballot, that candidate has expressed support for a government-run health-insurance system which would crowd out private insurers from the marketplace. But you haven’t heard a Democrat with electoral ambitions call it “single-payer” in quite some time. In late 2017, the Democratic Congressional Campaign Committee warned aspiring lawmakers that “single-payer” is loaded with negative connotations whereas “Medicare for all” sounds less threatening. The Democratic strategy is working, too. Both Republicans and Democrats are warming to the idea of a single-payer system. But if Democrats ever find themselves having to deliver on promises, they are going to be caught between the implacable ideologues that make up their base voters and the reality that single-payer is unfeasible.
Though they disagree on some of the particulars, both the Koch brothers-funded Mercatus Center at George Mason University and the non-partisan Urban Institute agree on one thing: The single-payer plan advanced by Bernie Sanders in 2016 would cost roughly $32 trillion over ten years. There is no viable way to fund a program that would consume virtually every dollar of annual federal outlays. Even if Congress doubled the revenues it takes in from individual and corporate income taxes (an average income tax hike of $24,000 annually, according to the Urban Institute’s calculations), it wouldn’t cover the costs. Voters wouldn’t stand for that, anyway.
According to Sen. Sanders, these estimates miss the mark because his single-payer plan is a cost-savings mechanism. All the country must do is commit to forcing every doctor and hospital to accept per-patient Medicare reimbursements that would be 40 percent lower than the rates paid out by private insurers. Then the nation has to hike tax rates by 10 percent of annual GDP instantly; no gradually phasing in this shock to the economy. Finally, the federal government must overcome the objections of 150 million privately insured who say they are losing their health insurance and it must crush the lobbying efforts of the private insurance industry, which will undoubtedly object to the nationalization of its assets.
Democratic boosters of this plan appear to believe that the Triumph of the Will can overcome the objections of doctors, hospitals, and providers to the lower quality of care that will be the result of payouts below the providers’ current cost of delivery. Indeed, ideologically stubborn resistance to this unyielding arithmetic is hailed by some as the mark of a visionary. Eventually, though, Democrats in Washington will have to join their counterparts in places like Vermont and California and come to terms with the fact that the private health-insurance marketplace will endure in some form or another.
Democrats will have to deliver something, but whatever it is will no doubt fall short of what they promise today. And when the Democratic Party disappoints the starry-eyed socialists at their flanks and ratifies Republican critiques of their ideological crusade, they’ll have fallen into the trap Republicans built for themselves over the better part of a decade.
