Democrats are shifting toward single-payer. Here’s proof.


The architects of Hillary Clinton’s agenda are moving toward Bernie Sanders’s vision for universal health care — a step that shows how far the Democratic Party’s center has shifted on policy since the 2016 primary.

On Wednesday, the Center for American Progress released a detailed, universal coverage plan that would offer Medicare to all Americans, enrolling newborns right at birth and allowing the federal government to set health care prices across the country.

“After we defeated repeal, it became clear that there would be a debate on the path forward for our country on health care,” says Topher Spiro, CAP’s vice president for health policy. “The debate is only going to gain steam. We thought we had some interesting ideas to contribute to that debate.”

Democrats have been moving toward the idea of a single-payer health care system in the past year. Presidential frontrunners like Sen. Elizabeth Warren (D-MA) and Cory Booker (D-NJ) spent last fall lining up to endorse Sanders’s (I-VT) plan for a Canadian-style health care system in the United States.

The CAP plan doesn’t envision quite as large a role for government as the single-payer system Sanders outlined. It would allow employers to continue offering insurance to workers — although it includes some strong incentives to switch those workers over to the public plan instead.

Importantly, though, the CAP and Sanders plans are similar in that they envision the federal government guaranteeing health coverage to all Americans through one more centralized program. This is quite different from Obamacare, where tens of millions remain uninsured because they can’t afford the premiums or they live in states that have not expanded Medicaid.

The Medicare Extra for All Plan, explained

Sanders has long modeled his single-payer plans on the Canadian system, where the government operates one health insurance program for all citizens. Under this setup, Canadians get an insurance card from their province.

The CAP plan looks more to me like many European countries: a heavily regulated, universal coverage program where the government standardizes the coverage all citizens receive. Under this scheme, the government sets prices and mandates a specific set of benefits — but allows a variety of health insurers to sell this coverage.

The Medicare Extra plan mandates that all health insurance cover a robust set of benefits including prescription drugs, hospital visits, doctor trips, maternity services, dental, vision, and hearing services.

The government would set the prices paid for all these services — unlike our current system, where thousands of insurers and hospitals haggle over fees that can vary widely from one place to another.

Low-income Americans would be enrolled in this plan without any premiums. Higher-income Americans would be expected to pay a monthly premium (at most, 10 percent of their income) — and pay deductibles and copayments (the exact amount of these is not set in the CAP plan, although Spiro said he is working with a modeling firm on making estimates).

The CAP plan would begin automatically enrolling newborns, the uninsured, and those turning 65 into the Medicare Extra program. Those who currently get coverage through federal programs — current Medicare enrollees, for example, as well as military members on TRICARE and government employees on the Federal Employees Health Benefits Program — would also be rolled into Medicare Extra.

Medicare Extra wouldn’t be the only game in town

CAP envisions a parallel program called Medicare Choice: insurance that offers the same package of benefits, with the same premiums and cost-sharing, but run by private insurers. This is meant to be a new version of Medicare Advantage, privately run Medicare plans that currently cover 34 percent of seniors.

These plans could “offer the same benefits as Medicare Extra and could also integrate complementary benefits for an extra premium.” This reminds me of the heavily managed competition we often see in countries like Germany and Switzerland.

Citizens of those countries get their health insurance from a whole slew of different insurers — Germany, for example, has hundreds of “sickness funds.” But those plans are so tightly regulated that they often look quite similar to one another and often end up competing on their quality of service.

This is not what health wonks would call a single-payer system; instead, they fall into the multi-payer category. But these systems arguably achieve the same goals as a single-payer system: providing universal coverage at a reasonable price to all citizens.

“Bernie Sanders has laid out a vision, and I think the debate is around how to fulfill the vision,” Spiro says. “There are several objectives that progressives have in common: to guarantee coverage, to eliminate underinsurance, to restrain prices charged by prices, to allow any American to enroll in the same plan if they want. These are things we’re all working to achieve.”

The CAP plan would still let companies offer health insurance

One of the most controversial parts of the Sanders plan is the decision to eliminate employer-sponsored insurance, moving all Americans to the government-run plan.

Most Americans who do have insurance currently get it at work — and most people who get insurance at work say they like their coverage, making the prospect of eliminating employer-sponsored insurance altogether very disruptive.

The CAP plan takes a more moderate approach here, letting employers continue to offer coverage to their workers so long as it meets certain federal standards. At the same time, it would give employers an alluring, simpler option: stop offering coverage and instead pay a payroll tax roughly equivalent to what they currently spend on health coverage.

I have no idea what decision employers would make here. Many smart health care observers thought that large companies would dump their workers onto the Obamacare marketplaces, where the federal government would subsidize their premiums rather than the employer. But that didn’t happen, and we saw that employers were quite reticent to disrupt their workers’ coverage.

Would things be different under the CAP plan? I think they might be, mostly because the public Medicare Extra plan that CAP envisions is much more generous than current Obamacare plans. Workers may get just as good a deal, if not better, by switching to the government plan. But as we saw with Obamacare, employer-sponsored coverage is very sticky, and companies may be reticent to move employees onto a new plan.

Democrats are in the middle of a shift to the left on health care — thanks, in part, to Republicans

My colleague Dylan Matthews wrote a piece last year noting the remarkable shift in liberal health politics around single-payer:

This CAP plan has some different ideas than the Sanders plan but generally aims in the same direction. And the fact that it even exists — that CAP didn’t present a less expansive plan, like a Medicare buy-in plan, for example — suggests that the consensus we saw emerging last fall is only getting stronger.

Part of this seems to have been catalyzed by the Republican attempts to repeal the Affordable Care Act and the party’s general refusal to work toward Obamacare’s implementation.

“The repeal debate and efforts to undermine the ACA have influenced me, and I think others, deeply,” Spiro says. “I don’t think we’ll get any cooperation in designing the current system to function optimally.”

As the Huffington Post’s Jonathan Cohn astutely tweeted, you probably wouldn’t see this push toward a more regulated, more comprehensive health care system if Obamacare were functioning as its drafters hoped.

But now you’re seeing a pretty clear signal that Democrats want to shift to the left on health care — and are starting to work through the nuts and bolts of what it would look like to take the rest of the country with them.



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