In December, a senior policy aide to House Speaker Nancy Pelosi gave a presentation to insurance industry representatives telling them not to worry about Medicare for All.
The presentation, reported by The Intercept, outlined a number of problems for single-payer health care, including "cost," "implementation challenges," the existence of other spending priorities, the creation of winners and losers, and stakeholder—which is to say, health care industry—opposition. It's a telling sign of how divided Democrats remain on the issue, and a preview of the looming intra-party war over single payer.
Looked at one way, Democrats are moving quickly to embrace single-payer health care. Much of the party's 2020 field has embraced the idea, and Sen. Kamala Harris (D-Calif.), whose campaign rollout last month probably received more attention than any of her competitors, has gone so far as to defend the idea that today's private insurance market should be eliminated, which is essentially what the Medicare for All plan put forth by Sen. Bernie Sanders (I-Vt.) calls for.
But although many of the party's rising stars are rushing towards the idea, the old guard is hanging back, and acknowledging some of the difficulties of the project. After Harris' remarks on Medicare for All last week, for example, Sen. Dick Durbin (D-Ill.), who ranks second in Senate Democrats' leadership, offered a more skeptical assessment, saying, "It would take a mighty transition to move from where we are to that." Other Democrats, including Harris' fellow Democratic senator from California, Dianne Feinstein, responded similarly.
Although the Pelosi aide's insurance industry presentation predated Harris' remarks, it's really just a more detailed version of the same set of objections, which is that Medicare for All, as envisioned by Sanders, would be expensive, difficult, and disruptive. The presentation urged a focus on other issues—defending Obamacare, lowering drug costs, slowing the growth of health care spending, and pushing towards universal coverage via the system that is already in place. It was a brief for liberal incrementalism of the kind that supporters of Sanders-style Medicare for All reject.
Blue Cross Blue Shield, the insurer reportedly present at the meeting, would neither confirm nor deny that the presentation happened, but there's little reason to doubt the story. Not only did The Intercept publish a reproduction of the slide show that accompanied the presentation, it's essentially what Pelosi herself has been saying in public for years. In 2017, as the story notes, Pelosi warned that the public didn't like the idea of single-payer, and that it is difficult to implement if you're not starting from scratch. "This is an idea that if we had a tabula rasa, if we were just starting clean, would be the most cost-effective way to go forward. We don't have that," Pelosi said in an interview with Joy Reid. "Over 120 or 150 million people in our country have employer-based access to their health coverage and insurance."
Which is another way of saying that Pelosi saw, and probably still sees, value in defending the false but politically necessary proposition that President Obama relied on to sell the Affordable Care Act: If you like your plan, you can keep your plan. Harris, Sanders, and other proponents of Medicare for All in its strongest form do not.
This is the conflict that will define not only America's health care debates in the coming years, but much of Democratic Party politics, which has been pulled further and further to the left, and which has elevated health care to the top of the priority list. And while the party's radicals will no doubt continue to sing the praises of disruptive single-payer plans (an aide to Rep. Alexandria Ocasio-Cortez (D-N.Y.) tweeted last week that the elimination of private insurance was a "feature, not a bug"), I expect that the party's more seasoned political strategists will be more hesitant, if not directly opposed.
In the end, that will probably mean embracing the label of Medicare for All, but applying it to something less than full-on single-payer—a Medicare buy-in proposal, or a public option (an insurance plan run by the federal government), which is, notably, what Durbin suggested last week when responding to Harris. Indeed, the specific policy meaning of Medicare for All has already become somewhat ambiguous, with some, like Sanders, using it to denote single-payer, and others repurposing it to describe lesser forms of government-driven coverage expansions. So while Medicare for All will probably win out in the Democratic party as a slogan, I suspect it will not be as the strict single-payer system that Bernie Sanders and his fellow socialists imagine.
Progressives no doubt bristle at finding Democratic leadership making essentially the same criticisms of single-payer that critics on the right have made for years—that the legislative price tag would be too high, that it's too disruptive and too politically risky. But the problem for Medicare for All boosters is that for all their enthusiasm, virtually all of the evidence suggests these criticisms are right.