Health care was a key factor in Democratsâ€™ victory in the 2018 midterm elections, and it should be a big plus in 2020 as well. The shared Democratic position â€” that every legal resident should have access to affordable care, regardless of income or health status â€” is immensely popular. The de facto Republican position â€” that we should go back to a situation in which those whose jobs donâ€™t come with health benefits, or who suffer from pre-existing medical conditions, canâ€™t get insurance â€” is so unpopular that G.O.P. candidates consistently lie about their own proposals.
But right now, two of the major contenders for the Democratic presidential nomination, Joe Biden and Bernie Sanders, are having an ugly argument about health care that could hurt the partyâ€™s chances. There are real, important differences between the two menâ€™s policy proposals, and itâ€™s fine to point that out. Whatâ€™s not fine is the name-calling and false assertions. Both men are behaving badly. And for their partyâ€™s sake, and their countryâ€™s, they need to stop it.
Letâ€™s back up. There are, broadly speaking, two ways a country can try to achieve universal health insurance. One is single-payer: The government simply pays the bills. The other retains a role for private insurance but relies on a combination of regulations and subsidies to ensure that everyone gets covered.
We donâ€™t have to speculate about how these systems would work in practice, because every advanced country except the U.S. has some form of universal coverage. Some, like Canada and Britain, use single-payer (in Britain the government also operates the hospitals and pays the doctors). Others, like Switzerland and the Netherlands, have a large role for private insurers.
The clean little secret of health care is that both approaches work when countries try to make them work. In fact, we can see both systems at work right here in America.
More than 100 million Americans are covered by Medicare or Medicaid, which are both single-payer programs; despite Ronald Reaganâ€™s ominous warnings back in 1961, neither destroyed American freedom. Since 2014, millions more have been covered by the Affordable Care Act, which was underfunded and has been subject to extensive Republican sabotage; nonetheless, states like California that have tried to make the act work have experienced huge declines in the number of residents without insurance.
Which brings us back to the Democratic quarrel.
Sanders, of course, has made Medicare for All his signature proposal. Could such a plan work? Absolutely. But there are two valid criticisms of his proposal.
First, it would have to be paid for with higher taxes. While many people would find the increased tax burden offset by lower premiums, the required tax increases would be daunting. And while Sanders has in fact proposed a number of new taxes, independent estimates say that the revenue theyâ€™d generate would fall far short of what his plan would cost.
Second, the Sanders plan would require that roughly 180 million Americans give up their current private insurance and replace it with something different. Persuading them that this would be an improvement, even if true, would be a tall order. Indeed, thereâ€™s good reason to believe that eliminating the option of retaining private insurance would be an electoral loser. (Elizabeth Warren and Kamala Harris, take heed.)
On the other side, Biden is proposing to build on Obamacare. That can sound like tinkering at the edges. But his actual plan is much bigger and better than is widely realized, with large increases in funding, a public option, and more. It would, arguably, bring the A.C.A. close to the standards of successful European systems.
That said, the Biden plan would preserve the crazy-quilt, Rube Goldberg aspects of our current system, which impose a lot of unnecessary costs and make it too easy for people to fall through the cracks.
So thereâ€™s plenty of room for a good-faith Sanders-Biden argument. Unfortunately, thatâ€™s not the argument theyâ€™re having.
Instead, Sanders is arguing that only single-payer can purge â€œcorporate greedâ€ from the system â€” an assertion belied by European experience â€” and broadly hinting that Biden is in the pocket of corporate interests. Thatâ€™s a criticism you can level about some of Bidenâ€™s past policy positions, like his advocacy of the 2005 bankruptcy law. But itâ€™s not a fair criticism of a health plan thatâ€™s actually pretty good, and which most people would have considered radical just a few years ago.
For his part, Biden is declaring that the Sanders plan would undermine Medicare. In fact, it would enhance current recipientsâ€™ benefits. And itâ€™s a bad sign that Biden, who poses as Obamacareâ€™s great defender, is using a G.O.P. scare tactic familiar from the utterly dishonest campaign against the A.C.A. No Democrat should be stooping to that level.
Unfortunately, Biden and Sanders will be appearing on different nights during the next Democratic debates. So it will be up to other candidates, or the moderators, to put them on the spot. Itâ€™s time for both men to stop poisoning their own partyâ€™s well.