For the first time in ten years, Democrats can play offense on health care, because Republican heartlessness and incompetence have delivered a political gift: they’ve tried to sabotage Obamacare to cause intentional pain, and people know it. Republican efforts on health care show they want to take us backward—to an era of higher prices, less coverage, and less stability. Democrats should seize this opportunity and look to the future, saving health care and ushering in a new era of stability and security.

Sixty-one percent of the public now believes that the GOP and Trump are responsible for problems with the Affordable Care Act (ACA, a.k.a. Obamacare), including a majority of independents and Republicans.¹ Unfortunately, as The Washington Post, Axios, POLITICO, and others have noted, a jumbled Democratic narrative threatens the party’s advantage on this issue.² In this memo, we recommend one simple message: Trump is killing your health care; we are saving it.

For Democratic officeholders and candidates who are already on record supporting single-payer health care, we respect your principled advocacy. For everyone else, we urge caution before endorsing single-payer. Republicans are salivating to use single-payer as a cudgel to get back on offense on health care because it is not as popular as advocates suggest. And single-payer raises many serious policy questions.

As former Congressman and health care icon Henry Waxman put it: “[Don’t] turn this winning issue into a loser by imposing litmus tests — in particular, by demanding that all Democratic candidates support a single-payer bill, such as Medicare for all.” 

The Winning Narrative: Saving Your Health Care

On health care, all politics isn’t local, it’s individual. As Democratic pollster Geoff Garin has said: “More than any other issue, voters litigate health-care policy on a personal basis and really sweat the details. The Republicans learned, to their sorrow, how much the details matter when support for the idea of repeal and replace collapsed after voters saw the reality of repeal and replace.”³

Democrats can hold the GOP accountable with one simple message: Trump is killing your health care; we are saving it. This has three core elements:

• Trump and Republicans are taking us backwards and killing your health care: They are sabotaging your health coverage, driving up costs, putting your plan in doubt, and carving up Medicare and Medicaid to pay for tax cuts.
• Democrats want to save your care: Democrats have a plan to keep your coverage affordable and will fight to cut your premiums and deductibles.
• Don’t bring back the bad old days: Democrats will stop insurers from once again being able to penalize you for a pre-existing condition, or because you turned 50, or because you’re a woman.

Rep. Conor Lamb (D-PA) has proven that this is a winning message. Here is how he campaigned on health care: 

I believe that every American has a right to go see a doctor when they're sick, and that means every American has a right to health insurance they can afford.

The Affordable Care Act has flaws, but it has provided affordable coverage to more than a million Pennsylvanians who were previously uninsured.

Our representatives in Congress should be working together to build on that progress, fix what isn't working, and make the law better. Instead, Republicans in Congress spent the past year trying to take health insurance away from people with no plan to replace it. Now, costs are likely to go up for many of us, especially those with preexisting conditions. That is unacceptable, and it's a failure of leadership.⁴

Democrats can also add a positive note by saying they will work to lower the cost of your coverage by getting better value from drugs and medical care as well as making health care affordable for everyone. The cost issue is a top priority for voters, and one where Democrats have a clear advantage. Democrats should tout their individual ideas to fight the most egregious forms of excessive costs that arise in health care.

The Risky Approach: Scrap Obamacare for Single-Payer

Officeholders and candidates should support the principled health care position they feel is best. That said, those examining the issue should be wary of embracing single-payer based on political expedience and a belief that it is best way to win the policy and messaging debate. Single-payer (also known as Medicare-for-All), introduced by Senator Bernie Sanders, is a welcome addition to the debate on universal coverage. There is an active grassroots campaign behind it, and some polls show a degree of top-line support for the idea.⁵ But this support evaporates when voters hear counter-arguments. And in the course of a campaign, voters surely will hear them.

As Democrats think through the right path to universal coverage, they should ask some basic questions about single-payer: 

Will single-payer mean that I will lose my coverage?

For 320 million people the answer is yes. One hundred fifty-seven million get coverage through their employer.⁶ Another 163 million are covered under the ACA, Medicaid, Medicare Advantage, federal employee and union plans.⁷ Under single-payer, all of the people in those groups—91% of the covered public—will lose their plan and receive a new, unfamiliar plan from the federal government. Right now, 80% of those with employer-sponsored plans are satisfied with their coverage. People are more worried about losing what they have, especially when they are unsure of the replacement. As the old saying goes, a bird in the hand is worth two in the bush.

What does it cost and how is it paid for?

Nobody knows. Despite years of advocacy for single-payer, no one has offered comprehensive cost estimates. The most reliable appraisal, from the Urban Institute, puts the price tag at $32 trillion over a decade. To his credit, Sen. Sanders has proposed a series of tax increases to pay for his bill.⁸ It includes raising taxes by 8.4% on everyone (2.2% paid by families and 6.2% paid by employers, which most economists believe would come out of the employee’s paycheck).⁹ Moreover, all of the Sanders’ tax increases add up to less than of the Urban Institute’s cost estimate. Additional tax increases may well be necessary.

What happens to abortion coverage if the government is running health care?

Tough to say. Private insurance plans discreetly handle the politically sensitive health issues that blow up in Washington. Abortion, for example, is covered by most private health plans. It is not covered by any public health plan except in the rarest of cases. Sen. Sanders included reproductive rights in his bill (that’s good), but his bill would make all abortion coverage taxpayer-funded. Even women in the military do not have coverage for abortion. Why should anyone believe that single-payer would be the exception? Indeed, Planned Parenthood has opposed single-payer state initiatives.¹⁰

What can be learned from single-payer initiatives in the states?

Voters just aren’t into it. Vermont tried to implement single-payer and failed in 2016. A Colorado ballot initiative was resoundingly defeated in 2016, losing in every single county by at least double digits. Massachusetts failed with multiple attempts before it successfully enacted a reform that became the model for the ACA. If states are the laboratories of democracy, the experiments show that even the most progressive governments can’t deliver single-payer.

In blue and purple states, single-payer has racked up quite a record:

• In 1994, California’s single-payer Proposition 186 won just 26.6% of the vote.
• In 2002, Oregon’s single-payer ballot measure garnered 21.5% of the vote.
• In 2016, Colorado’s single-payer ballot Amendment 69 got 21.2% of the vote.¹¹ It lost by 24 points in Boulder, one of the bluest counties in America.¹²

Will single-payer deliver the promised cost savings?

Not likely. Sure, single-payer could be cheaper than our current system, but it would entail things Congress is not likely to do. For example, dramatically cutting salaries for health care professionals and reimbursements to doctors and hospitals like they do in Europe are major cost-savings. Registered nurses make $68,000 here, compared to $44,000 in the UK, $47,000 in Germany, and $51,000 in Canada.¹³ There are 3 million nurses in America. Lower reimbursements could shut down many hospitals, since they would be forced to accept much lower Medicare reimbursement rates for all of their patients. Medicare pays 47% less than commercial health plans for in-patient hospital care, according to the Congressional Budget Office.¹⁴

What will the opposition say?

A lot. Republicans will note that single-payer means massive taxes and government-run health care. As columnist Dana Milbank notes, single-payer is “a liability for Democratic candidates in the swing districts and Republican states that Democrats need to win to retake the House and Senate.” Indeed, Republicans were gleeful at the bill introduction, for good reason. It allowed them to stop talking about their Obamacare sabotage and focus on a health care plan that takes away people’s coverage and puts it in the hands of the government. Greenberg Quinlan Rosner Research and GBA Strategies have identified eight potential GOP attacks.¹⁵ There are probably more.

Why are a lot of progressive health care leaders cool to single-payer?

They can see around the corner. It’s easy to see the grassroots energy behind single-payer, but many question whether fueling that fire is helpful:

Henry Waxman (former Congressman): [S]ingle-payer is no policy panacea. Medicare is hugely successful and popular, but most beneficiaries purchase private supplemental insurance to reduce the burden of large out-of-pocket costs. The most prominent single-payer bill would eliminate all out-of-pocket costs for Medicare, a move whose astronomical costs would require tax increases at politically suicidal levels.¹⁶

Paul Krugman (New York Times): Democrats could eventually find themselves facing a Trumpcare-type debacle, unable either to implement their unrealistic vision or to let it go.¹⁷

Ron Pollack (Families USA): Maybe we should hit pause before we get on this bandwagon.¹⁸

Jonathan Chait (New York magazine): A single-payer plan would be nice, in a world that looks nothing like the one we inhabit.¹⁹

Drew Altman (Kaiser Family Foundation): [Single-payer could] help Republicans, who own the problems in health care now, switch the target to the Democrats and their sweeping new health reform plan.²⁰

Can branding single payer as Medicare-for-all overcome its weaknesses?

Single payer advocates have recommended that candidates do not use the term single payer and instead take advantage of the popularity of Medicare with the term Medicare-for-all.²¹ Medicare is indeed popular as a program for older and disabled Americans who have no other source of comprehensive coverage. But most Americans have coverage with their employer. Once they find out that under Medicare-for-all they would have to pay higher taxes instead keeping their own coverage, public opinion swings from 55% support to 60% oppose.²² Support drops by even more when they hear the argument that Medicare-for-all would give the government too much control over health care.²³

Conclusion

There are many paths to universal coverage and controlling costs—single-payer is one of them but far from the best, either substantively or politically. We believe that Democrats should focus on rescuing and improving Obamacare and attacking Republicans for their unconscionable efforts to take health care coverage away from so many Americans. That’s critical for Democrats as they fight get majorities in Congress in 2018. A national debate over single payer is what Republicans want since it would turn health care from a winning Democratic issue into a losing one.