I have supported Medicare-for-all all my adult life. This is not a post about the pros (there are many) or the cons (maybe a few) of a single payer health insurance system like Medicare-for-all. This is a post about political realities.
It’s a critical issue since competing health insurance policies/visions have become a major dividing line between those who favor Bernie and those who favor Hillary. And it’s the kind of divide that defines the differences between the two candidates.
Hillary Clinton has previously supported a single-payer system in theory, but has cautioned supporters that it’s not politically feasible. Leave it to our friends in the GOP to help document this history.
There is no question Bernie Sanders is foursquare behind single-payer and has made a version of this approach a centerpiece of his campaign. He has sponsored several pieces of legislation to promote a Medicare-for-all/single-payer approach, most recently a bill introduced in December 2013, Bill # S.1782. Tellingly, this bill garnered zero cosponsors in the Senate.
Of course, at least part of the reason there were no cosponsors on that bill is because no one in Washington believed such a bill had any chance of passing so soon after passing ACA and during a time when the media was in a frenzy over the problematic launch of HealthCare.gov.
But the truth is single-payer has never secured majority support in Congress.
Keep in mind, when the Senate brought up the Affordable Care Act in 2009 and 2010, the Democrats had 60 votes (though for only about four legislative months). And during this time, the high water mark for Democrats who supported the public option in the ACA was 51 votes, nine short of the filibuster proof majority.
Supporting a public option under the ACA is significantly less ambitious than supporting a full-on Medicare-for-all program. So, at least going by very recent history, it seems obvious on its face that today, with 14 fewer votes in the Senate, Democrats have a much steeper hill to climb to even bring up a Medicare-for-all approach in the Senate.
In the House, Rep. John Conyers has introduced a Medicare-for-all bill, H.R. 676. For the record, this bill has 60 cosponsors, all of them Democrats. During the previous Congress, he introduced a similar bill that garnered 63 cosponsors. To pass legislation in the House, you need a simple majority of 218, more than 3-times the number of cosponsors.
So, how do we get to 60 votes in the Senate and 218 votes in the House for a Medicare-for-all approach? Well, it comes down to some pretty tough math. Safe to say that there is not likely to be a single Republican vote to replace our existing private health insurance-based system with a Medicare-for-all approach. So to get to 60, Dems must win a lot of races across the country this year, in 2018 and 2020. And we can’t afford to lose more than just a handful of seats we currently hold in both houses of Congress.
Just look at the races we have in front of us, starting in the Senate for simplicity’s sake. Democrats and two Independents (including Sanders) who caucus with Democrats currently hold 46 seats in the Senate. The three Democrats who voted against public option in the Senate Finance Committee in 2009 (Baucus, Lincoln, Conrad) are no longer in the Senate. Same is true of the other Democrats who were either on the fence or against the public option (Lieberman, Landrieu, Ben Nelson, Bayh, and Pryor are all gone). The problem is these Democrats were mostly replaced by very conservative Republicans. Only Lieberman and Conrad were replaced by Democrats. And Lieberman’s replacement, Senator Murphy, is the only one who might be open under the right circumstances to a single-payer system.
While some more moderate Democrats, Like Warner from VA and McCaskill of MO, were open to the public option in 2009, it is very difficult to know how they would vote if Medicare-for-all was offered as a full-fledged repeal and replace of our existing health insurance system. My best estimate would give us about 30-35 Senate Democrats who could be counted on as yeses on single payer.
So, not only do we need to net at least 14 seats in the Senate, we need to gain about twice that many as yeses on single payer. This is a very tall order.
Now, I hear many Bernie supporters suggest the possibility of Bernie leading a movement that will help win votes down ballot. Even if that’s the case, the math is just really hard. This year, I currently count only Illinois and Wisconsin as GOP-held Senate seats likely to flip to Democrats. Four other GOP seats look like toss ups right now — NH, FL, OH, and PA. You might add AZ to that list, but that seems like a stretch. At the same time, there are two Dem seats in the toss-up range — NV and CO.
Even if we run the table on all these close races, that gets Dems to 53 seats in the Senate. I think this is the best case scenario in 2016, whether Bernie or Hillary is our nominee.
The problem is we have a tougher road in 2018 with many more Dem seats up in a mid-term election. And I think we’ll be very lucky to have a simple majority in the Senate after 2018.
It’s way too early to project 2020, but there are a lot more GOP seats up that year. So at least by the numbers, we should look better in that year. Still, it’s a very steep mountain to get to 60 in the Senate.
Okay, so where does that leave us? Some might say you only need 60 votes if we allow the filibuster rule to continue. I think it’s again extremely unrealistic to suggest that Dems would dream of forcing through something as monumental as single payer with simple majority vote in the Senate. That is just not going to happen.
Then there is the argument that electing Bernie would at least keep single-payer in play. Sure, I can understand that. And if that motivates voters, I don’t have any problem with that.
I just hope we all keep in mind how difficult this fight is going to be. I have a hard time seeing us getting the votes needed for this until after the 2020 census and some good redistricting. I think we need to keep the issue alive, but it won’t be until the 2024 presidential race before we can realistically run on Medicare-for-all as a viable, realistic plan that has a chance of passing — and that’s only if we continue to see big failings in the health insurance industry and Obamacare start to fall apart due to rising costs and/or other market failures.
By no means am I trying to undercut Bernie or support Hillary. I’m legitimately undecided and have until Virginia’s primary in March to figure it out. I’m just saying that no matter who wins the nomination, they will both face the same math in Congress, which will make single-payer very nearly impossible in the next 4-8 years.