Single Payer or Bust?

https://www.nytimes.com/2017/08/14/opinion/single-payer-or-bust.html

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News arrived last week that Our Revolution, the political group that arose from Bernie Sanders’s presidential campaign, is going to back primary challenges against Democrats who aren’t deemed ardent enough in their support for single-payer health care. “We’re not going to accept no more hemming and hawing,” said the group’s president, Nina Turner. “Make your stand.”

This makes for a potentially fateful moment — in the history of the Democratic Party, and in the history of our ever more polarized politics. It’s also, as alluring as such uncompromising passion can sound, very substantively misleading.

If you’re a normal person who doesn’t have much time to burrow into the details of policy, you can be forgiven for thinking that the health care choice we face in this country is between the current improving but still inefficient and dissatisfying status quo and a single-payer system. After all, single payer, in which the federal government acts as every American’s insurance provider, is the only alternative that ever gets discussed.

But that isn’t the case. Single payer is a policy choice, not a principle. The principle is universal coverage. Single payer is one way to get there. It’s how Britain and Canada do it. But there are other ways. France uses a hybrid system that is mostly but not wholly single payer. Germany uses private insurers, mostly nonprofit, but gives the government more control over how they operate. In Japan, private insurance supplements a government-run basic insurance program.

And other advanced countries use still other combinations of methods. They’re not all single payer, but they all achieve universality or something very close to it. They’re all more efficient than our system, and citizens in those nations have access to good, basic cradle-to-grave coverage.

It might be that a German-style model would be an easier lift politically in this country, or a slow expansion of Medicare rather than the immediate Medicare-for-all position Our Revolution advocates. It’s logical, from a political bargaining standpoint, for the group to have that as an opening position. But the way Ms. Turner talks, it sounds less like an opening position than a full-on demand.

That brings us to the matter of the threatened primaries. One key difference between the right and the left in this country has been that the right has worked an inside game while the left has mostly remained outside the system. That’s how it’s been since the late 1950s, when the modern conservative movement was first organizing itself and its leaders made the conscious decision to work within the Republican Party.

The Republicans of that time were full of centrists and even liberals. It wasn’t a club many die-hard conservatives wanted to join, but they did. They decided that rather than fight the power, they wanted to become the power. And, of course, they have.

On the left, meanwhile — and I mean here the real left, not as conservatives use the word, to mean anything to the left of, well, them — the urge has always been to fight the power. I think leftists have always felt more psychologically comfortable working outside the system. But Mr. Sanders’s campaign seems to have changed that.

So the left will now bore from within, to hijack an old labor-movement term of art. It’s much more strategic than marching, and it makes political sense. But it brings potential complications of which liberals should be aware.

The main reason the congressional Republican Party has moved so far to the right is that Republican legislators all live in fear of a primary challenge from the right. If they deviate from orthodoxy on something major, they know there is someone in their district or state who’ll run against them — and whose challenge will be backed by two or three deep-pocketed right-wing groups.

As Barney Frank so memorably put it to New York magazine as he was leaving Congress, making reference to the hard-right former representative from Minnesota: “They’re not all Michele Bachmann. Half of them are Michele Bachmann. The other half are afraid of losing a primary to Michele Bachmann.”

If Our Revolution has its way, a similar situation will someday prevail on the liberal-left side. I have moments when I think maybe this will be fine. Certainly, taking over the Republican Party hasn’t hurt the right; it has flourished.

At the same time, it’s worth remembering that there are a lot more conservatives in this country than liberals. The gap has narrowed in the last two years, but it’s still plenty wide. So it’s reasonable to be concerned that the day could come when Our Revolution is able to elect nothing but single-payer-supporting Democratic senators — but that there might be only 38 of them.

A final point: An energized left working inside the Democratic Party will heighten polarization even more.

Throughout most of American history, our parties have been amalgams of factions that disagreed fiercely on many matters and duked it out at the quadrennial convention. That had its downsides too, but it did mean that there was some overlap between the parties, whether Democrats and Whigs in the mid-1800s or, later, Democrats and Republicans.

That began to change after the Democrats embraced civil rights and emergent social issues forced the parties to choose sides. By now, of course, there’s no overlap at all. Ideological homogeneity has hit both parties, but it’s much more intense on the Republican side, because of the primary threat, and because the conservative media have created a large base that demands orthodoxy. If we begin to see primary challenges on the Democratic side similar to those mounted by Tea Party Republicans in recent years, we’ll have two equally rigid camps.

I’m a liberal who’d be perfectly happy with single-payer health care in this country. But I also support a functioning political system. If there had been even a few Republican moderates who voted for the Affordable Care Act, Congress might actually be fixing it in good faith right now. It appears that ship has sailed, on partisan seas that are about to get choppier.