It’s a convenient and popular slogan, but efforts to make Medicare-for-All a litmus test for Democrats is being resisted by progressive wonks and journalists. Photo: Bryan R. Smith/AFP/Getty Images

There is a split happening among left-of-center folk over health care. On the one hand, the progressive wing of the Democratic Party is pushing the party to make support for single-payer health-care — often referred to as “Medicare-for-All” — a litmus-test issue. On the other hand, both policy and political concerns about the feasibility of Medicare-for-All are spreading, even among highly self-conscious progressives.

The first site of this conflict was California, where the Democratic-controlled state Senate passed a single-payer bill without any funding component, then Democratic assembly speaker Anthony Rendon put a hold on future action until a plan is put together to finance the universal benefits involved. By most estimates, the single-payer bill would cost more than the entire state budget. Single-payer advocates, led by RoseAnn DeMoro, executive director of the California-based union National Nurses United, attacked Rendon as a back-stabbing sellout. The issue became the leading edge of a hostile takeover effort of the state party by Democratic progressives.

The neat left-versus-center symmetry of the California battle was shattered when one of the state’s most consistently progressive journalists and policy wonks, David Dayen, published a piece accusing NNU and other single-payer advocates of knowingly dissimulating about their plan’s feasibility:

They’re completely wrong. What’s more, they know they’re wrong. They’re perfectly aware that SB562 is a shell bill that cannot become law without a ballot measure approved by voters. Rather than committing to raising the millions of dollars that would be needed to overcome special interests and pass that initiative, they would, apparently, rather deceive their supporters, hiding the realities of California’s woeful political structure in favor of a morality play designed to advance careers and aggrandize power.

Dayen noted a number of bars to any simple legislative enactment of a single-payer system, but emphasized a constitutional provision that requires reservation of about half of state revenues for education. The provision can only be overridden by a state constitutional amendment approved by voters. And that could only begin to happen in 2018. But that isn’t keeping advocates from hurling thunder-bolts at pols like Rendon who are acknowledging reality.

But the temptation to make support for single-payer a litmus test for Democrats is hardly limited to California. With Bernie Sanders prepared to introduce a new Medicare-for-All bill in the Senate, efforts to make support the only option for Democrats who want to avoid left-bent primary challenges are already under way, as Politico reported earlier this month:

As for outside groups, it’s clear that they have a strategy to make single payer a litmus test issue politically, while never acknowledging the process hurdles. With so many single-payer supporters in California and across the country unaware of the facts, playing this cat and mouse game is at best a sin of omission, at worst the kind of dishonesty that breeds cynicism in the public when it learns it was conned.

“Our view is that within the Democratic Party, this is fast-emerging as a litmus test,” said Ben Tulchin, the pollster for Sanders’ White House run.

And here’s Nina Turner, president of Our Revolution, the organization created by Bernie Sanders supporters to carry on his political legacy:

“Any Democrat worth their salt that doesn’t unequivocally say Medicare-for-all is the way to go? To me, there’s something wrong with them,” said former Ohio state Sen. Nina Turner, president of Our Revolution. “We’re not going to accept no more hemming and hawing. No more game playing. Make your stand.”

Shortly after this pronouncement, however, a very comprehensive article by Joshua Holland appeared in America’s flagship left-progressive publication, The Nation, with this very direct headline: “Medicare-for-All Isn’t the Solution for Universal Health Care.”

[T]he activist left, which has a ton of energy at the moment, has for the most part failed to grapple with the difficulties of transitioning to a single-payer system. A common view is that since every other advanced country has a single-payer system, and the advantages of these schemes are pretty clear, the only real obstacles are a lack of imagination, or feckless Democrats and their donors. But the reality is more complicated.

Holland notes that there are a variety of models for something like “single-payer” in other countries, and none of them exactly resemble an expanded Medicare. The idea that getting rid of private insurance profits will instantly and massively reduce health-care costs is myopic as well, given widespread profiteering by hospitals, doctors, and others participating in the system. Beyond that, facile polling showing “Medicare-for-all” with vast popularity doesn’t take into account the inevitable backlash when Americans happy with their health insurance have to give it up:

Centrist Democrats will no doubt be one obstacle to universal coverage, but a more fundamental problem is that compelling the entire population to move into Medicare, especially over a relatively short period of time, would invite a massive backlash.

The variety of options and the difficulties of transition lead to an unmistakable political conclusion. Holland says that the litmus test should be believing that health care is a human right, rather than believing that Medicare-for-All is the only valid way of getting there.

Rather than making Medicare-for-All a litmus test, we should start from the broader principle that comprehensive health care is a human right that should be guaranteed by the government—make that the litmus test—and then have an open debate about how best to get there. Maybe Medicaid is a better vehicle. Perhaps a long phase-in period to Medicare-for-All might help minimize the inevitable shocks. There are lots of ways to skin this cat.

At a minimum, it’s time to get past the idea that anyone who doesn’t embrace Medicare-for-All, as it’s currently defined, must be some kind of neoliberal hack.

Respected progressive health-policy wonk Harold Pollack probably best crystallized this pushback to a Medicare-for-All litmus test at Democracy Journal:

Single payer is not, in itself, a principle. It is one way to organize health-care financing. A regulated patchwork of private insurers undergirded by public subsidies and the individual mandate is another. In other words, these arrangements are means to an end, not ends themselves. After all, most American progressives would be thrilled to see the Dutch or German health-care systems enacted here, though neither of these is actually single payer in the sense that Medicare is.

The end—the core principle at stake—is universality. A wealthy and humane democracy must provide decent health coverage to everyone—coverage that actually works to prevent and treat serious illness, injury, and disability. On this principle, progressives are in total agreement. We’re no longer debating the goal of universal coverage. We’re debating how to get there. And it’s important to remember that.

It is unclear at this point whether the argument within the progressive left over single-payer will eclipse the long-standing argument between left and center over health-care policy. So long as Obamacare remains under imminent threat from Republicans, it’s unlikely Democrats will go to war with each other over what should eventually replace it. But the Medicare-for-All slogan is a powerful totem for those who believe Democrats must abandon their attachment to private-sector involvement in health care and other key areas of public policy. So it won’t go away just because it might not work. But quite possibly it can be understood as a means to an end rather than an end in itself.