Since losing the White House last year, a growing number of Democrats in Congress have embraced the idea of universal, single-payer health care, setting up an inevitable confrontation between the liberal and centrist wings of the party over its future.

Emboldened by Hillary Clinton’s 2016 defeat, and the Republican effort to dismantle former President Barack Obama’s signature health-care law, progressive lawmakers and activists are trying to move single payer into the party mainstream. There are signs the idea is winning traction: For the first time ever, a majority of House Democrats have signed up to support “Medicare for all” single-payer legislation, a threshold crossed in the aftermath of the presidential election. A number of influential Senate Democrats have also expressed support for single payer in the midst of the current Republican health-care push, which is now in doubt as Senate Majority Leader Mitch McConnell pushes for an Obamacare repeal vote.

“If you’re serious about real health-care reform, it has got to be on the agenda, and I would hope that as many Democrats as possible support it,” Senator Bernie Sanders said in a recent interview after a rally against the GOP health-care bill  in Kentucky, where he promised that “as soon as we defeat this terrible Republican proposal,” he would introduce his own Medicare-for-all legislation. “It’s going to be a tough fight,” Sanders said, “but it is a fight that has to be waged, because it is the only rational solution to the health-care crisis that we face.”  

Sanders, the most popular figure on the American left, has used his higher post-election profile to advocate for single payer, while progressive firebrand Senator Elizabeth Warren has called single payer “the next step” for the party. Senator Kirsten Gillibrand has publicly said that “we should have Medicare for all.” Senator Kamala Harris, frequently buzzed about as a rising star in the party, recently told a crowd in her home state of California that “as a concept, I’m completely in support of single payer,” though she added the caveat: “but we’ve got to work out the details, and the details matter on that.”

Democrats are far from united over single payer, however. For the moment at least, Democratic congressional leaders are reluctant to endorse single-payer legislation. Senate Democratic Leader Chuck Schumer has been non-committal when pressed by reporters on single payer. House Democratic Leader Nancy Pelosi has not signed onto the House “Medicare-for-all” bill that has gained in popularity, though she has expressed support for the concept, and argued that states could act as laboratories for single payer. And talk of single-payer in the midst of the current congressional health-care fight has highlighted divides within the party.

“Single payer is a huge distraction from the enormously important task that Democrats have in front of them, which is defending Obamacare,” said Matt Bennett of the center-left think tank Third Way. “And assuming that Republicans don’t completely blow up the system, there’s a lot that needs to be done to shore it up. I think the fact that Pelosi and Schumer have stayed on the sidelines [over single-payer] is very telling. That might be a signal that leadership does not want to head in this direction.”

It’s not even clear how much Democrats who have embraced single payer would agree on if the policy debate moved from abstract discussion to nitty-gritty details. Locked out of power in Washington, Democrats have no ability to implement single payer. That gives liberal lawmakers the freedom to talk up the idea of government-administered, taxpayer-funded health insurance that would provide universal coverage, without necessarily needing to know exactly how they would achieve it.

“Democrats are essentially using ‘single payer’ as an easy shorthand to convey that they want a health-care system that works better and costs people less,” said Sherry Glied, a former health-policy adviser to the George H. W. Bush, Clinton and Obama administrations. “But just invoking the concept on its own doesn’t say much about policy specifics. To some extent, this is the flip-side of what Republicans did by advocating for repeal and replace [of the Affordable Care Act] when Obama was president. For Democrats, single payer may even be a more attractive proposition when there’s a Republican president since they don’t have to deal with the hard trade-offs that would be at stake if a bill could actually pass.”

The legislation that a majority of House Democrats have signed onto, sponsored by Democratic Representative John Conyers, proposes an expansion of the federally-administered Medicare insurance program to all Americans funded in part through existing government revenue and an increase in taxes on the top five percent of earners. The text only runs 30 pages long.

The legislation Sanders plans to introduce is expected to be significantly more detailed. Exactly what it calls for, and which Democrats sign on, will shed light on how widespread support for single payer is among Senate Democrats, and where liberal lawmakers agree and disagree.

Part of the appeal of single payer among liberal lawmakers is that many Democrats want to advance a health-policy agenda that goes beyond defending the ACA, a law that congressional Republicans have relentlessly attacked for nearly a decade, and which even Democrats agree has its flaws. Now that former President Obama is out of the White House, the party is less duty bound to act as though Obamacare is as good as it gets.

“There’s not much political mileage in it for us to say we’re for the ACA when it’s become the whipping post for the Republican Party,” Democratic Representative Jamie Raskin of Maryland said in an interview. “We [will] defend the ACA pragmatically as the right foundation upon which to build, but we can define the goal as health care that will include all Americans.”

Advocating universal health-insurance coverage also has the advantage of creating a stark contrast to the legislation Republicans in Congress have spent months attempting to enact, which non-partisan analysts have estimated would leave millions of Americans without health insurance.  

“It’s not just about single payer, it’s about inclusionary politics,” Democratic Representative Peter Welch said in an interview. “It’s about a government that has policies that are going to work for everyone, not just a select few. That’s really the heart of the message. It’s broader than just health care.”

The fact that Sanders gave Clinton a serious challenge while running on a platform that advocated Medicare for all has also created momentum. The Vermont senator’s campaign created visibility for the issue, and Clinton’s defeat in the general election has emboldened the party’s progressive wing to argue even more strongly that a centrist, incrementalist approach to Democratic politics is not the answer as the party seeks to rebuild.

“Bernie Sanders’s candidacy helped catapult single payer back to prominence in the Democratic Party. He is the only serious contender for the presidential nomination to back single-payer in the past quarter century,” said Jonathan Oberlander, a professor of social medicine and health policy and management at the University of North California-Chapel Hill.

But even Sanders, who has been rallying opposition to the Republican health-care plan since President Trump took office, concedes the Democratic party hasn’t completely warmed to the idea of single payer.

Asked if single payer will be part of a policy platform that Democratic congressional leaders are putting together, Sanders said: "I would like it to be in it, do I think it will be in it? Probably not. I think it's too radical [in the view of Democratic leadership] at this moment.” A Democratic leadership aide said the package will be an economic agenda that focuses on job creation, growth and wages, and that Democrats must continue to focus on defeating Republican efforts to repeal the ACA as the top health-care priority.

The Vermont senator added: “I think that clearly the momentum is with us. I think we will have far more Democrats on board with single payer when I introduce it now than I have in the past … we'll see where leadership goes." The last time Sanders introduced his Medicare for all legislation was in 2013. At that time, there were no co-sponsors.

As Democrats in Congress hold out the possibility of single payer, there is evidence that public opinion has moved in favor of such a system among Democratic voters. A majority of Democrats, at 52 percent, support the idea of providing health coverage through a single, national insurance program run by the government, according to a June poll from the Pew Research Center. The poll found that the percentage of Democrats who support that idea had grown by 19 percentage points since 2014. Pew also reported that the share of Americans who say “health coverage is a government responsibility remains at its highest level in nearly a decade.”

If Democrats controlled Congress, and the presidency, there would still be challenges to any kind of single-payer push, not least among them the question of how expensive it would be. Attempts to implement single payer in California and Vermont, liberal stronghold states, have run aground amid contentious debates over the cost required for implementation.

Whether single payer wins wider buy-in within the ranks of the Democratic Party, and its leadership, may hinge in part on how the debate over implementing it unfolds. Polling suggests that support for single payer drops when people are told it could lead to elevated government spending, and Republicans are already going on the attack against Democrats over single payer, attempting to brand it as exorbitantly expensive.

For now, Democrats who support single payer will keep making the case for the idea in the hopes of convincing party leadership, and whoever runs for the White House in 2020 that it’s a winning issue. Democratic Representative Ro Khanna suggested in a recent interview that future candidates may be able to argue that while Trump has made ambitious health-care promises—like his vow of “insurance for everybody”—only Democrats, running on single payer, will be able to deliver on the pledge of universal coverage.

“What the first person who runs in 2020 ought to say to Donald Trump is ...‘you promised the American people more benefits, less costs, more coverage, and you didn’t deliver. You know as well as we know that the answer is single payer. So, why are you not supporting Medicare for all?’,” Khanna said in an interview. “That’s a great attack, and a great message,” he added. “My view is that this is really going to become the platform of the Democratic Party.”


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