During Thursday’s debate, the two candidates for the Democratic nomination were offered the opportunity to engage one another’s ideas for the path forward on healthcare reform. In the last few weeks, Bernie Sanders has advocated for a “single payer” system to replace the Affordable Care Act, which Hillary Clinton has said has no chance of passing Congress and would mean scrapping a flawed but useful system that could instead be reformed.

At the debate, Clinton stated that she had been “fighting for universal coverage” for many years, but that rather than starting over from scratch that “we should build on what we have”. Bernie Sanders countered, correctly, that every other liberal democracy has provided universal healthcare for much less money than the US spends, and that the American system still falls far short of this standard.



Here’s the thing: they’re really both right. Sanders is correct that while the Affordable Care Act was a major progressive achievement, the American healthcare system still insures too few people for far too much money, and considerably more needs to be done. And Clinton is right that the it’s possible to build European-style healthcare out of the framework created by the ACA.

The key to fixing our system, though, is to understand that single-payer is far from the only model – and it’s not the same as “universal coverage”.

Since Sanders released his single-payer plan, it has come under attack from some critics for being vague and unrealistic; his supporters have responded that expecting a high level of policy detail in a campaign proposal is unrealistic. Sanders defenders have a point: campaign policy proposals that make implausibly optimistic assumptions and ignore downsides are more the rule than the exception.

The details of the 2008 Democratic candidates’ proposed healthcare proposals were important then because there was a reasonable chance that something would actually pass; the same cannot be said for the chance of passing a major overhaul in 2017.

The problem with Sanders’s single-payer proposal isn’t that it is too vague to allow voters to assess its feasibility and its flaws. The problem with his plan is that it reinforces the idea that European-style universal healthcare is synonymous with “single payer”; that is simply untrue. There are models that deliver similar or better results than single-payer systems, and they are more politically viable within the American system.

In terms of viability, it’s vital to understand the massive economic disruption that implementing single payer in this day and age would cause, and how that would make it a political non-starter regardless of which party controlled Congress. As Paul Starr argued recently in the American Prospect, when President Harry Truman proposed universal health insurance, healthcare costs were only 4% of GDP; had the US gotten single payer then, healthcare would be much less costly today. Since then, however, healthcare costs have ballooned, and that makes a public takeover of the health insurance industry far more difficult.

From the Social Security Act to the Affordable Care Act, major progressive reform in the US has always involved compromises to buy off vested interests. And, even in countries where there are fewer institutional mechanisms to thwart change, medical lobbies have serious influence. Even with the advantages of a political system that makes it easier for major reforms to pass, nationalized healthcare was able to pass in the UK only because Labour Health Minister Aneurin Bevan “stuffed the mouths” of medical practitioners “with gold”. It’s one thing to do that in the UK in 1948; the amount of gold that would have to be stuffed into the millions of mouths of the American health industry to make single payer viable in the 21st century would require insanely high (and obviously politically unsustainable) levels of taxation and would also defeat much of the purpose of converting to single payer in the first place.

To implement a single-payer healthcare system from scratch in 2017 would mean not only nationalizing the insurance industry, but severely cutting payments to doctors, hospitals and other areas of the healthcare industry if it were to bring any cost savings. A lot of people working for politically powerful lobbies would be thrown out of work or bankrupted, and many others would be looking at whopping pay cuts; that would never be politically viable even if it was desirable as policy.

To put it another way, single payer in the contemporary US faces intertwined political and policy problems that are insurmountable. The effects of the lack of cost controls in the American system for decades can’t be undone overnight.



Still, the fact that single payer is probably politically unviable shouldn’t stop anyone from focusing on single payer as a long-term goal if it was the only way of achieving real universal healthcare. But it’s not.

Many liberal democracies, including Switzerland, France and Germany, have achieved true universal coverage with hybrid public/private models. The Netherlands actually changed its single-payer system to a hybrid system in 2006. When compared to single-payer Canada, the hybrid models in general rank better in quality and efficiency and are as or more equitable. And like single-payer, they deliver better results for far less money than the US spends.

Particularly given that there’s no way that single-payer would be as cheap in the US as it is in Canada, single payer is probably less desirable than the hybrid model even if we ignore the former’s political unfeasibility.

But Sanders and Clinton are right that, in the long term, something at least approaching European-style universal healthcare is possible. Many countries have built excellent healthcare systems out of better versions of the ACA model: expanded (and in the case of Medicaid, improved) public insurance combined with better-regulated and subsidized private markets. Progress can be made towards this incrementally, as Clinton has proposed; it can be done in another big statute but it doesn’t have to be.

If we’re going to get to universal coverage, though, liberals need to get beyond conflating “single payer” and “European-style healthcare.” (And I’ve been as guilty of that as anyone.) Universal health coverage is a case in which Sanders’s idealism and Clinton’s realism can in fact end up in the same place.

But when thinking about Sanders’ as-yet vague healthcare reform proposal, progressives who want reform – and maybe even Sanders himself – need to be committed to its goal of universal coverage rather than being strictly committed to any particular path like “single payer”.