Republicans Learn to Love Single-Payer Health Care

Who wants a Medicare-for-all system? A plurality of Republicans, apparently. A new Economist/YouGov survey shows 46 percent of the party in favor of "expanding Medicare to provide health insurance to every American." Just 38 percent are opposed. This comes on the heels of a January Pew poll where 30 percent of Republicans agreed that the government has a responsibility "to make sure all Americans have health coverage." That looked like a pretty high number at the time, but these new results make it seem small.

If you were alert, you could see this sentiment building for a while. About a year ago, a Gallup poll suggested that 41 percent of the GOP liked the idea of replacing ObamaCare with federally funded universal health care. That number was probably inflated by people willing to endorse anything framed as an alternative to ObamaCare, but you can't say that about this year's results.

Meanwhile, you don't see New York Post headlines like this every day:

That's F.H. Buckley, the chief author of Donald Trump Jr.'s speech at last year's Republican convention; he's making the case for "universal health care, on the Canadian model." Buckley's been for single-payer for years, so the news here isn't that he feels this way. It's that this seemed an opportune time to publish his arguments in The New York Post. That and the reminder that such sentiments can be found in the president's orbit as well as the president's voting pool.

For an extra little thrill, Vox has this:

The article below that headline jumps somewhat haphazardly from the alt-right to mainstream (or at least semi-mainstream) conservatives, so that center-right figures like Buckley and Christopher Ruddy appear alongside the likes of Richard Spencer. But it makes its case: A lot of people under that broad "alternative right" umbrella, from Spencer to Mike Cernovich to Mencius Moldbug, have either signalled that they're open to a single-payer system or endorsed it outright.

All of this is striking, but none of it should be shocking. Rank-and-file Republicans may love to grumble about big government, but most of them made their peace with entitlements long ago; if they can handle that tension, they can probably handle another one. And if enough Republican voters decide that this is what they want, there will be Republican politicians who are willing to oblige them. The last time Mitt Romney ran for president, he attacked Barack Obama for allegedly cutting Medicare. It's not hard to imagine a future GOP nominee warning the electorate that those dastardly Democrats are plotting to roll back Berniecare.

Right-wing intellectuals might have a trickier time making the switch, but they have at least two paths open to them. Many nationalists are already on the road toward embracing a herrenvolk welfare state that bestows its services on the designated in-group while excluding outsiders. The alt-rightists may be inclined to frame this in purely racial terms, but that's not actually necessary—many on the right embrace a sort of rainbow nationalism that isn't limited to white people. At any rate, there will be a broad agreement on the fact of the boundary even if there's some disagreement about where it should be drawn.

This is not really new. Way back in 2006, while marking the anniversary of Bill Clinton's welfare overhaul, I called immigration

the one area where welfare still has an impact on the culture wars. In the old days, you could rile up red-meat conservatives by arguing the relief rolls were filled with shiftless, undeserving bums living high on the taxpayers' dime. Today, the immigration debate centers not on services meant for the desperate but on services meant for everyone: schools, hospitals, public amenities. Immigrants aren't accused of pretending to be poor or pretending to look for a job. They're accused of pretending to be Americans, of taking goods that rightfully belong to all us citizens regardless of class.

Those old culture-war complaints about the underclass came roaring back with the financial crisis. But the nationalist argument didn't exactly go away, and it's not hard to see it adjusting itself to make room for health insurance among those benefits guaranteed to the in-group.

So that's one path. The Vox piece discusses it in some detail, with an eye on how it resembles the positions taken by populist parties in Europe. The other approach has a much briefer cameo in Vox's story:

[John Derbyshire] laments the fact that Americans are unwilling to accept a true free market in health care—but argues that single-payer makes more sense than the current hodgepodge of insurance subsidies and regulations and tax breaks. "Citizens of modern states will accept no other kind of health care but the socialized or mostly socialized kind," he said on a 2012 episode of his podcast, Radio Derb. "This being the case, however regrettably, the most efficient option is to make the socialization as rational as possible." Single-payer, he concludes, would involve "less socialism, and more private choice," than "what we now have."

This is an argument you sometimes encounter on the left end of the libertarian movement: that single-payer might actually be less statist than the current corporate-state setup. The only novelty here is hearing it from Derbyshire, who is neither left nor libertarian.

There is a basic truth underlying this idea, even if the argument eventually goes off the rails. In the wake of World War II, as other western nations developed expansive welfare states in which the government provides benefits directly, the American welfare state sometimes took a more indirect form—a public-private partnership in which the government sets the parameters and businesses deliver the goods. This wasn't deliberately designed so much as it gradually grew from policies developed on the fly, such as the tax incentives that made employer-provided plans the primary means of receiving health insurance (and made insurance the primary means of paying for health care). The result was a dysfunctional, bureaucratic system that's pretty easy to criticize from a free-market perspective, and indeed free-marketeers have been hammering away at it for several decades now. People like Derbyshire borrow the libertarian critique, but instead of proposing radical reform they use it as a handwave: Sure, what I'm suggesting isn't a free-market setup, but neither is what we have now, so whaddaya gonna do?

Now, it's possible to imagine a system that expands government coverage in some ways while at the same time becoming more market-oriented. Singapore has universal health insurance, but it also has a competitive market largely driven by out-of-pocket payments; if a proposal like that were on the table, a lot of libertarians might back it as a step in the right direction. A Canadian-style system would have a harder time finding libertarian takers.

But we are not speaking of libertarians here. We are speaking of the Republican Party. Between the nationalists and the hand-wavers, the GOP won't have much trouble accomodating voters interested in expanding the entitlement state. I wouldn't bet my money that Trump will sign any big overhaul of the health care system, but if he does, don't be surprised if it looks more like this than like anything the Freedom Caucus wants.