Former Secretary of State Hillary Clinton and independent Sen. Bernie Sanders revived their oft-contentious sparring over health care Thursday night in Milwaukee during the latest Democratic presidential debate, this one on PBS. It was the first debate since Sanders' big win in the New Hampshire primary on Tuesday, and the last before the candidates compete again in the Nevada caucus on Feb. 20.

For Sanders, the debate was an opportunity to keep the Bernie train rolling after an impressive victory; for Clinton, it was a chance to step in and re-take control of a race in which she is still the front-runner, but that is looking more complicated than it once did.

From the get-go, Clinton decided to go all-in on her realism versus Sanders' idealism, her technocratic approach to laying out what is concrete and achievable versus his much more nebulous political revolution, as their early exchange on health care made clear.



Sanders, for those catching up, is proposing a single-payer, "Medicare-for-all" system, akin to those in France or Canada; Clinton has been, rightfully, noting the political impracticality of such a plan, and instead favors a grab bag of items to build upon the Affordable Care Act, aka Obamacare, a difference she went to great lengths to emphasize.

"What we have tried to do, and what President Obama succeeded in doing, was to build on the health care system we have, get us to 90 percent coverage. We have to get the other 10 percent of the way to 100. I far prefer that and the chances we have to be successful there than trying to start all over again, gridlocking our system, and trying to get from zero to 100 percent," Clinton said in response to Sanders' latest single-payer pitch, adding later that "we have a special obligation to make clear what we stand for, which is why I think we should not make promises we can't keep."

Lack of political realism is certainly a fair critique of Sanders; his proposals are dead on arrival in Congress so long as the GOP holds the House of Representatives and Paul Ryan retains the speaker's gavel. The problem for Clinton is this: So are her's.

For instance, Clinton has called for letting Medicare negotiate directly with drug companies for lower prices. It's a great idea! But Congress explicitly barred Medicare from doing so and isn't likely to reverse itself under the GOP. Ditto her plan for more refundable tax credits to those facing higher than expected out-of-pocket costs or her proposal to cap the cost of prescription drugs.



Ryan and the Republicans have voted 60-something times to repeal the Affordable Care Act. Though the law has certainly taken less precedence on the campaign trail of late, I doubt they'd suddenly wake up in January 2017 overjoyed about working with a President Hillary Clinton to improve upon it.

In fact, the same can be said for a lot of her domestic policy agenda. Building on the Dodd-Frank financial reform law? A tax on high-frequency trading? Barring a serious congressional shakeup, they're dead and deader. The relative moderation of her proposals doesn't change the fact that neither she nor Sanders is going to win over House Republicans or Senate Majority Leader Mitch McConnell. Even if Democrats flip the Senate, which is possible, McConnell has already shown that he's willing to filibuster the entirety of a president's legislative effort into oblivion if the other side has less than 60 votes.

And herein lies the problem that the Obama years revealed so well and that Clinton hasn't truly come clean about publicly: The minority party knows full well that not cooperating with the president is key to electoral success. Moderation doesn't change that. At the end of the day, I imagine Sanders and Clinton would be equally as effective at vetoing another Obamacare repeal effort sent by a GOP Congress.



Now, it's true that Sanders has not fully explained what a shift to a single-payer system would practically mean for people; it's a giant disruption for those who like the health insurance they have and really wouldn't get to keep it this time. He also isn't fully forthright about the fact that it's not just insurance companies, but doctors and other special interests that aren't as scary as Big Pharma, who lose under his proposal and would flip out if it ever looked like it could come to pass. He also seems to have some math issues.

But it's unclear to me why Clinton should receive such plaudits among the political class for proposing "realistic" plans that won't pass, while Sanders is castigated for proposing what U.S. health care would look like in his ideal world, though it also won't pass. Is her argument that, should Democrats flip the House someday, she has ideas that can receive adequate support? That's, well, uninspiring. And single-payer is still pretty darn popular among Democrats.