Would TrumpCare inevitably lead to universal health care?

Bernie Sanders doesn't seem convinced. The Vermont senator recently said his top priority on health care is stopping Republicans' Better Care Reconciliation Act: "We are focusing all of our energy on trying to defeat this terrible piece of legislation." He has also come out in favor of improvements to the Affordable Care Act as an interim step. Does this represent a change in policy on the part of the long-time advocate of single-payer health care? Not at all — he still plans to introduce a Medicare-for-all bill later this year. And his analysis of the situation is perfectly coherent. Passing TrumpCare would make getting a universal, mostly or entirely public health care system harder, not easier.

In an otherwise excellent recent piece in The New Republic, Brian Beutler takes the opposite tack. He applauds Sanders and the left wing of the Democratic Party for its "selfless" defense of the Affordable Care Act as it faces devastating attacks from House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell. To Beutler, the left is making a sacrifice, defending people facing the loss of insurance now even though "the enactment of TrumpCare would shorten the way to single payer." But I don't think this is quite right. Rather, the left is actually acting in both its short and long-term interests in defending the ACA.

The case that passing TrumpCare would make single payer more likely — also made recently by Vox's Ezra Klein — is straightforward. If Republicans wreck the ACA's insurance exchanges, Democrats will have no choice but to embrace single payer as a long-term goal. But one obvious problem with the argument is that it's not necessary for BCRA to pass for this to become the consensus Democratic goal. Two frontrunners for the 2020 Democratic nomination, Sanders and New York Sen. Kirsten Gillibrand, favor Medicare-for-all, which makes it extremely likely that all the major candidates for the nomination will follow suit.

To people who think that the primary barrier standing in the way is the fecklessness or corruption of Democratic Party leadership, a Democratic president who favors single payer is most of the battle. But in reality it's more like 5 percent of the battle. Rather, the difficulty of getting to something like single payer is rooted in formidable structural barriers. In addition to the basic fact that the large number of veto points in the American system protects the status quo, there are two major factors that make the immediate abolition of all private health insurance an incredibly difficult political lift. And Republicans gutting the ACA wouldn't make them any less so.

The first is that the longer you wait to do a public system, the harder it is to accomplish. When countries like the U.K. and Canada passed nationalized and single-payer programs, respectively, health-care spending represented a much lower percentage of GDP. This made things easier for two reasons. First of all, these countries were able to overcome strong opposition from medical professionals by throwing money at them. American policy-makers won't be able to buy off doctors, hospitals, and other vested interests that way; indeed, any viable universal public insurance would have to give them a major haircut. This won't be easy. And, second, all of the countries that created universal programs decades ago have been able to control costs throughout that period. Keeping costs lower through public cost controls over time is a lot easier than cramming them down once they've been allowed to grow, as has happened in the U.S.

The second major barrier to single payer or a similar program is that people who have employer-provided insurance or Medicare generally like it. The ACA's exchanges don't present much of a problem; any well-designed public program is likely to give most people getting their insurance through the exchanges a better deal. Employer-provided insurance is a different story — a lot of people will likely to be made worse off (although this will probably be less true over time.) And even if Medicare is preserved as is, people already in Medicare have nothing to gain from a universal program and may perceive a threat. In health care, as in many things, people are strongly risk-averse.

The difficult impediments standing in the way of single payer can be seen in the recently failed California proposal. Some of the problems with the bill were California-specific, but some have national implications. The designers of the program tried to deal with the second problem by offering public insurance with generous benefits that would leave very few people worse off. But this ran the bill straight into problem No. 1 — the bill would have been exorbitantly expensive. The answer to the question of whether the levels of taxation necessary to fund the program would be politically viable is implicitly answered by the fact that the Senate bill didn't contain a funding mechanism at all.

It should be obvious at this point that passing TrumpCare wouldn't mean an easy path to universal health care. The Republican bill would make the first problem even worse while doing nothing about the second. Universal public insurance would still be a very heavy lift, and with Medicaid having been gutted the next Democratic government would just be starting further away.

This doesn't mean that universal health care with mostly public insurance is an impossible goal. But, as Sanders says, it's much more likely to happen through a gradual, largely voluntary expansion of Medicaid and Medicare rather than by the immediate elimination of all private insurance (including good insurance provided by employers.) Passing TrumpCare would just be another barrier in the way. In other words, fighting to preserve the ACA isn't inconsistent with universal health care — it's an important part of the struggle.