The Single-Payer Siren Song
‘Medicare for All’ may become the Democrats’ version of ‘repeal and replace.’
By William A. Galston
The Wall Street Journal
September 13, 2017
There must be something special in the waters of Lake Champlain. In 2011 newly elected Vermont Gov. Peter Shumlin announced his intention to shift his state to a single-payer health-care system. He pursued that goal until late 2014, when a study by his staff and consultants projected that it would require imposing a payroll tax of 11.5% and raising the personal income tax by as much as 9.5 percentage points. “The risk of economic shock is too high,” Mr. Shumlin concluded as he withdrew his proposal.
There were political considerations as well. Despite successfully campaigning on a single-payer platform in 2010 and winning re-election in 2012 and 2014, Mr. Shumlin never succeeded in persuading a majority of his constituents to support his signature idea. An April 2014 survey found Vermont split down the middle, with 40% of residents approving and 39% disapproving. Perhaps the prospect of increasing the state budget by 45% gave Vermonters reason to doubt the wisdom of an abrupt shift to single-payer health care.
Vermont is not some random canary in the mineshaft. The Green Mountain State is among the most liberal in the country. Barack Obama prevailed by 37 percentage points in 2008 and 36 points in 2012. Hillary Clinton’s snake-bitten 2016 campaign managed a 26-point victory. The state is ethnically homogeneous, with a median household income above the national average. It is hard to think of a state better positioned to embrace single-payer health care, yet a determined governor couldn’t get close to pushing it through.
But now Democratic presidential aspirants are rushing to endorse Vermont Sen. Bernie Sanders’s soon-to-be-released national single-payer plan. Sens. Elizabeth Warren and Kamala Harris already back it. Sens. Cory Booker and Kirsten Gillibrand have announced plans to co-sponsor it as well.
From the perspective of the contest for the Democratic nomination in 2020, this strategy is easy to understand. Mr. Sanders came closer to upsetting Mrs. Clinton than most observers thought possible. For now, the progressive wing of the party is energized, and the party’s ideological center of gravity has shifted.
In 2000, when Al Gore defeated Bill Bradley for the Democratic presidential nomination, 44% of Democrats regarded themselves as moderate and only 28% as liberal. By 2008, when Mr. Obama narrowly prevailed over Mrs. Clinton, the moderates’ share had fallen to 41% while the liberal share had increased to 33%.
Since then, the pace of ideological change has accelerated. Today, liberals make up the largest share of Democrats—48%. Moderates have fallen further, to only 36%. And the conservative wing, nearly one-quarter of the total in 2000, now amounts to barely one-seventh of the party.
If you want to win the 2020 Democratic presidential nomination, it might seem, the best strategy is to emerge as the champion of its newly dominant progressive faction, and coming out for single-payer might seem the best way to do it.
Whether this is the best formula for winning a general election contest is another matter. Sens. Warren, Harris, Booker and Gillibrand are coastal Democrats from bright-blue states. Ohio Sen. Sherrod Brown, a veteran populist from a swing state that Donald Trump carried by a stunning eight points in 2016, has conspicuously declined to endorse the Sanders bill, preferring to build bipartisan support for a more modest proposal to allow Americans to buy into Medicare when they reach 55. Democrats should ask themselves which of their elected officials better understands how to win back the Midwestern states that made Mr. Trump president.
This is not just a political calculation. From a policy standpoint, the danger is that “Medicare for All” will become the Democrats’ “repeal and replace ObamaCare.”
In May 2016, the Urban Institute—not previously known as a hotbed of conservatism—released its analysis of the Medicare for All proposal Sen. Sanders offered during his presidential campaign. The study found that if the plan were enacted into law, the federal government would absorb the bulk of the current spending by states, localities, employers and households. Federal spending would rise by $2.5 trillion in the plan’s first year, and by $32 trillion over the first decade.
A parallel study conducted by the bipartisan Tax Policy Center found that Mr. Sanders’s revenue proposals would raise only $15.3 trillion over the first decade, leaving a gap of $16.6 trillion between expenditures and revenues. “The proposed taxes,” the Urban Institute observed, are “much too low to fully finance the plan,” and “additional sources of revenue would have to be identified.”
It will be interesting to see whether Sen. Sanders’s new proposal can meet these objections. Even if it does, Democrats interested in regaining a national majority should look before they leap.
There must be something special in the waters of Lake Champlain. In 2011 newly elected Vermont Gov. Peter Shumlin announced his intention to shift his state to a single-payer health-care system. He pursued that goal until late 2014, when a study by his staff and consultants projected that it would require imposing a payroll tax of 11.5% and raising the personal income tax by as much as 9.5 percentage points. “The risk of economic shock is too high,” Mr. Shumlin concluded as he withdrew his proposal.
There were political considerations as well. Despite successfully campaigning on a single-payer platform in 2010 and winning re-election in 2012 and 2014, Mr. Shumlin never succeeded in persuading a majority of his constituents to support his signature idea. An April 2014 survey found Vermont split down the middle, with 40% of residents approving and 39% disapproving. Perhaps the prospect of increasing the state budget by 45% gave Vermonters reason to doubt the wisdom of an abrupt shift to single-payer health care.
Vermont is not some random canary in the mineshaft. The Green Mountain State is among the most liberal in the country. Barack Obama prevailed by 37 percentage points in 2008 and 36 points in 2012. Hillary Clinton’s snake-bitten 2016 campaign managed a 26-point victory. The state is ethnically homogeneous, with a median household income above the national average. It is hard to think of a state better positioned to embrace single-payer health care, yet a determined governor couldn’t get close to pushing it through.
But now Democratic presidential aspirants are rushing to endorse Vermont Sen. Bernie Sanders’s soon-to-be-released national single-payer plan. Sens. Elizabeth Warren and Kamala Harris already back it. Sens. Cory Booker and Kirsten Gillibrand have announced plans to co-sponsor it as well.
From the perspective of the contest for the Democratic nomination in 2020, this strategy is easy to understand. Mr. Sanders came closer to upsetting Mrs. Clinton than most observers thought possible. For now, the progressive wing of the party is energized, and the party’s ideological center of gravity has shifted.
In 2000, when Al Gore defeated Bill Bradley for the Democratic presidential nomination, 44% of Democrats regarded themselves as moderate and only 28% as liberal. By 2008, when Mr. Obama narrowly prevailed over Mrs. Clinton, the moderates’ share had fallen to 41% while the liberal share had increased to 33%.
Since then, the pace of ideological change has accelerated. Today, liberals make up the largest share of Democrats—48%. Moderates have fallen further, to only 36%. And the conservative wing, nearly one-quarter of the total in 2000, now amounts to barely one-seventh of the party.
If you want to win the 2020 Democratic presidential nomination, it might seem, the best strategy is to emerge as the champion of its newly dominant progressive faction, and coming out for single-payer might seem the best way to do it.
Whether this is the best formula for winning a general election contest is another matter. Sens. Warren, Harris, Booker and Gillibrand are coastal Democrats from bright-blue states. Ohio Sen. Sherrod Brown, a veteran populist from a swing state that Donald Trump carried by a stunning eight points in 2016, has conspicuously declined to endorse the Sanders bill, preferring to build bipartisan support for a more modest proposal to allow Americans to buy into Medicare when they reach 55. Democrats should ask themselves which of their elected officials better understands how to win back the Midwestern states that made Mr. Trump president.
This is not just a political calculation. From a policy standpoint, the danger is that “Medicare for All” will become the Democrats’ “repeal and replace ObamaCare.”
In May 2016, the Urban Institute—not previously known as a hotbed of conservatism—released its analysis of the Medicare for All proposal Sen. Sanders offered during his presidential campaign. The study found that if the plan were enacted into law, the federal government would absorb the bulk of the current spending by states, localities, employers and households. Federal spending would rise by $2.5 trillion in the plan’s first year, and by $32 trillion over the first decade.
A parallel study conducted by the bipartisan Tax Policy Center found that Mr. Sanders’s revenue proposals would raise only $15.3 trillion over the first decade, leaving a gap of $16.6 trillion between expenditures and revenues. “The proposed taxes,” the Urban Institute observed, are “much too low to fully finance the plan,” and “additional sources of revenue would have to be identified.”
It will be interesting to see whether Sen. Sanders’s new proposal can meet these objections. Even if it does, Democrats interested in regaining a national majority should look before they leap.
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