The 2020 Democratic presidential primary campaign is in many ways an argument between liberals and moderates over the path the Democratic Party should take, and on no issue has that argument been more intense than health care. Joe Biden has now released his health care plan, and while he’s presenting it as a rebuke of the more liberal candidates, in fact it represents a significant move to the left.

That’s not how he’s talking about it. The video Biden put out with the release of his plan was a direct attack on other Democrats for their crazy liberal ideas and their betrayal of Barack Obama. Here’s part of what he said:

“I understand the appeal of Medicare For All. But folks supporting it should be clear that it means getting rid of Obamacare. I’m not for that … I knew the Republicans would do everything in their power to repeal Obamacare. They still are. But I’m surprised that so many Democrats are running on getting rid of it.”

Now let’s look at what Biden actually proposes. Here are the basics:

• Create a public option “like Medicare” that would be open to anyone, including those who currently have insurance through their employer.

• In Republican states that refused to expand Medicaid, allow all eligible people to get the new public option for free.


• Automatically enroll low-income people in Medicaid or the public option when they interact with the government.

• Increase ACA subsidies to make insurance more affordable.

• Force drug companies to negotiate prices with Medicare.

There’s more in there on drug prices, abortion coverage, surprise billing, and other topics. But overall, this is not just fixing some problems with the ACA, it goes far past it. It’s extremely similar to the Medicare For America Act introduced by Reps. Rosa DeLauro and Jan Schakowsky.

If you are an advocate of single-payer, you’ll find this too much of a compromise. But that shouldn’t obscure the fact that it’s a much more liberal plan than the ACA, which Biden is talking about as though it’s sacrosanct.

That’s the important historical context: In 2009 when the ACA was being debated, a plan like this one would have been considered almost radically leftist. There were still some liberals who would have preferred a single-payer plan to the ACA, but in that moment, what those on the left wanted was to include a public option, a Medicare or Medicaid-like program that would be offered on the exchanges and compete with private insurers.


The history of the rise and fall of the public option is a bit complicated. But what it came down to is that support for it among moderate Democrats began to bleed, the White House made clear it wasn’t all that important to them. Sen. Joe Lieberman, who had become consumed with spite for liberals, declared that if a public option was included then he would join the Republican filibuster and kill the entire ACA.

Then and now, a public option was understood by both liberals and conservatives as the camel’s nose under the tent that could eventually lead to single payer or something like it. And the fact that even Republicans think that’s what would happen demonstrates that they don’t really believe what they say about private insurance being superior to government insurance.

After all, if government insurance was so miserable, no one would choose the option and it would wither away. But if liberals are right, then it will be attractive and affordable, and more and more people will abandon their private plans for the government plan. Market principles will determine the outcome, which is exactly what conservatives are afraid of. They see how much seniors love their Medicare and how popular Medicaid is, and they’re worried the same thing would happen with a public option.

So is it possible that a plan like Biden’s could be a step on the road to single payer? Not exactly, but over the long term it could wind up being pretty close. If this new public plan worked well, since it’s open to anyone you could see millions of people gravitate toward it. Eventually we’d have three large government insurers (Medicare, Medicaid, and Bidencare or whatever it would be called) and private insurers steadily shrinking. At some point liberals would say, “Why don’t we just combine these three into one program that covers everyone, and leave private insurers offering supplemental coverage?”

Then you’d have a system not too dissimilar from the one in France or the one in Canada, both of which combine universal government-sponsored plans with private supplemental plans, and both of which work much better than ours.

I’m not saying there’s no real difference between single payer and what Biden is proposing; there are important distinctions and a case to be made for the superiority of the former. But Biden, who is presenting himself as the candidate of moderation and incrementalism, wants to go a lot farther than Barack Obama did a decade ago. Which is reason for liberals to feel like they’re winning the argument.

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