America needs single-payer. But we also need to get real.
The debate over whether America ought to have single-payer health care might as well be over. The new fight will center on what single-payer means.
Pretty much everyone agrees that we all deserve access to health care, even those like Sen. Rand Paul (R-Ky.) who think that calling it a "right" is somehow an endorsement of slavery. Likewise, there is a broad consensus that the current public-private hybrid system of mandates, exchanges, networks, deductibles, premiums, co-pays, and HSAs is an expensive, unsustainable, psychologically and spiritually enervating farce. Some on the right have suggested that the real solution is to "get government out of health care," a content-free phrase that, except in rare cases, never actually means getting rid of Medicare, a proposal with no support outside the readership of Mises.org. Who knows? Maybe it would be possible to abolish government health care and still care for 320 million people via cash payments and private charity. Maybe Disney is going to release the unaltered theatrical Star Wars trilogy on Blu-Ray. Both of these things could happen, but the former won't. Get over it.
All of which is to say that no one should be genuflecting in front of Sen. Bernie Sanders (I-Vt.) simply because he managed to introduce a single-payer bill with 16 Democratic cosponsors. For one thing, it is not exactly a rigorously imagined piece of prospective public policy. There is a strong "everyone gets a pony" flavor to Sanders' proposal, which envisions a system far more generous than any other in existence. In his imagination, single-payer seems to mean gleaming prosperity for all rather than everyone getting his fair share. What he doesn't seem to recognize is that the reason some Americans, including himself and his fellow members of Congress, get great care is that many get very poor care or none at all. The whole point of socialism is to distribute benefits in a just and even manner, not to will into existence an unlimited number of brilliant surgeons and top-of-the-line facilities and state-of-the-art equipment accessible to everyone.
Mark my words: When America does get single-payer, it's going to be crappy, it's going to be gritty, and it's going to be free. It will be tedious like the DMV, but it will be there, rain or shine. Democrats need to decide whether it's worth pitching their tent on things like no out-of-pocket spending ever for anyone while millions of people would be happy just to have something that isn't going to disappear tomorrow.
These are the arguments and decisions that matter now. Public opinion has swung dramatically, and single-payer in some form is all but inevitable. But getting there will be a slog. Sanders and his fellow sponsors have a lot of work to persuade the Clinton-Schumer-Pelosi wing of their own party that single-payer is a good idea — and that's before they even attempt the serious business of bringing conservatives — including the not totally unsympathetic President Trump — on board.
To take just one thorny question that needs answering: Would abortion be covered under a single-payer plan? Democrats should not be stupid about this. If they want to stake their political fortunes on the idea that "terminating" a pregnancy is just as important as kids getting treated for leukemia or old people receiving their prescriptions, hurray, I guess. But such views remain outside the mainstream. Democrats will need to compromise to see single-payer become a reality.
Proponents of single-payer also need to employ a sales strategy I learned on the site of the worst job I have ever had. When I was an undergraduate working for my school's alumni association fundraising call center, we knew that nobody actually wanted to give us money and that sending people pledge cards in the mail was a dead end. So instead of giving people the choice of a mailed pledge card or just paying over the phone, we would simply ask, after the poor working stiff who had just gone $30,000 in debt for a worthless piece of paper had theoretically committed himself to giving us $25, "What credit card do you want to use? We accept Visa, MasterCard, Discover, and American Express." Our new donor handed over his credit card details with alacrity and enthusiasm.
In other words, proponents of single-payer need to stop conceding that theirs is one solution among many. Change the terms of the debate. Be deliberately, oafishly obtuse — and make a painfully exhausting show of being polite when your opponent is confused. You still won't sound as stupid as the people responsible for the GOP's failed ObamaCare replacement bills.
People of good will everywhere are coming around. The argument we need to have now isn't whether everyone deserves health care. It's a boring one about details like whether glasses and contact lenses — as opposed to treatment for glaucoma — are fully covered or whether middle-class Americans can be expected to pony up for their specs. Sadly for Democrats, this is not an argument that Bernie Sanders, whose heart is bigger than his adorable head, was born to make.