Hillary Clinton took aim at Bernie Sanders' single-payer health care plan on Monday, characterizing it as "turning over your and my health insurance to governors," specifically naming Republican Terry Branstad. It's a pretty clear reference to the many conservative states that have refused ObamaCare's Medicaid expansion — implying that Sanders would allow conservative states to opt out of his plan, and hence partially destroy all federal health insurance programs.
This is absolutely false.
She is referencing Sanders' single-payer bill he introduced in 2013. It would require each state to set up its own single-payer plan, and fold all existing federal health care programs, except for Veterans Affairs, into that system. While one might criticize that structure (more on this below), it is emphatically not optional. Under his plan, a federal board will oversee the system as a whole and take direct control of any state program that doesn't meet its requirements.
I reached out to both campaigns, but only the Sanders campaign responded. Warren Gunnels, policy director for the campaign, compared the bill to ObamaCare's structure for insurance exchanges, where each state may set up its own exchange calibrated to its own needs, but if they'd rather not, they will default to the federal exchange. If conservative states refuse to set up a single-payer plan to the government's liking, then their "citizens would receive coverage from the feds," he told me.
Now, that's still sort of a weird way to set up a single-payer system. Sanders routinely describes his ideal plan as "Medicare for all," and that program is completely under federal control. Setting up 50 smaller single-payer systems (or however many states choose to participate) would surely create much duplication of administration structure and hence waste. Worse, it provides a potential crack in which conservative hacks on the Supreme Court might rewrite the program to be optional — just like they did with ObamaCare and the Medicaid expansion. Medicare is already firmly established, so it's perhaps wiser to implement single-payer on a similar foundation. Clinton is wrong to say that Sanders' plan provides an opt-out as written, but Justices Antonin Scalia and Clarence Thomas might cook up some goofy faux-constitutional reason to force that into the legislation after the fact.
Sanders' bill was over two years ago, however. When I asked if the campaign was going to come out with an official campaign plan, Gunnels said they will do so quite soon, and are weighing exactly this state versus federal question. "Both options are attractive," he said.
But what makes Clinton's remarks so infuriating is that Sanders' partially-decentralized plan is a result of trying to strike a balance between ideal policy and the many milquetoast compromises centrist Democrats like Clinton herself have written into the health care system. ObamaCare grew from the policy debates of the 1993 reform failure, which Clinton oversaw, and the 2008 campaign, in which Clinton played a leading role. Its greatest failure — the refusal of conservative states to expand Medicaid — is a partial result of its state-centered structure. Sanders wouldn't be bothering with state-by-state single-payer if Clinton, President Obama, and the rest of the party hadn't handed so many federal healthcare programs to the states in the first place.
Naturally, Clinton wants to preserve ObamaCare: "I don't want to rip it up and start over," she said at the same event. But she is talking out of both sides of her mouth. On the one hand she doesn't want to dismantle the program whose signature weakness is a result of decentralization; on the other, she attacks Sanders' proposal for being insufficiently centralized. It's doubly hypocritical given her support for her husband's welfare reform, which granted the program en masse to the states, most of which destroyed it.
In any case, it's obvious what's happening here. Clinton has been flagging in the polls of late, and as usual she's turned to fighting dirty.