Throughout his insurgent campaign for the Democratic presidential nomination in 2016, one of Bernie Sanders’s chief rallying points was to question why the United States is the “only major country on Earth not to guarantee health care to all people.” Having taken the issue into the political mainstream, the independent senator from Vermont is turning his broad idea into something more concrete by rolling out a “Medicare for All” bill on the floor of the Senate on Wednesday. 
 
 Related: If Bernie Sanders wants to win 2020 election, he needs to control his supporters, Democrats say 
 
 Even Sanders has acknowledged that it’s “obvious” the bill has no chance of passing with the Senate (and House) controlled by Republicans. But he has already succeeded in pushing the issue further into the spotlight and pressuring Democrats to jump on board. Support for the bill has become a practical litmus test for the party’s 2020 presidential hopefuls. 
 
 After California Senator Kamala Harris signed last month, other potential 2020 candidates—Senators Cory Booker, Elizabeth Warren and Kirsten Gillibrand—were among those to take the number of bill co-sponsors to 11 as of Tuesday afternoon. 
 
 The simple tenant of the proposal is to put in place in the U.S. a single-payer system akin to that used in the U.K., France, Australia, Canada and others. These can differ from fully government-run national health services, as in the U.K., to France’s public/private hybrid. Whatever route they take, though, they offer universal health care and no requirement to get insurance through an employer. In the U.S., the current Medicare safety net, which now covers only people over age 65, would apply to all Americans. 
 
 “Health care must be recognized as a right, not a privilege,” Sanders argues. “Every man, woman and child in our country should be able to access the health care they need regardless of their income. The only long-term solution to America’s health care crisis is a single-payer national health care program.” 
 
 Sanders has said that the plan would in large part be paid for by a progressive tax system that would have the richest households paying more income, capital gains and estate taxes, among others. Existing health care expenditures would also go toward the plan. According to Sanders, his plan would save the American people and businesses $6 trillion over the next decade. 
 
 While there is widespread evidence to support the notion that a single-payer system is far more cost-effective than the current model in the United States, the exact savings under Sanders’s plan remains a topic for much debate. 
 
 Still, although Republicans and even more moderate Democrats aren’t rushing to sign onto a single-payer system anytime soon, polls have showed that Americans have already moved in that direction. A June 2017 Pew Research Center survey found that 60 percent of Americans said the federal government should be responsible for ensuring health care coverage for all Americans. 
 
 Update: An earlier version of this story misspelled the name of Kirsten Gillibrand. This has been corrected. ||||| (CNN) When Sen. Bernie Sanders did this in 2013, he did it alone. 
 
 On Wednesday, nearly four years later, Sanders introduced a new "Medicare for all" health care bill with a third of the Senate Democratic caucus by his side. 
 
 Flanked at first by New York Sen. Kirsten Gillibrand and Connecticut Sen. Richard Blumenthal, Sanders called the costs of the current system "insane and unaffordable," promising that the average family would benefit financially under his plan "because you will no longer be writing checks to private insurance companies." 
 
 For those whose taxes would go up, he added, "that expense will be more than offset by the money are you are saving with the elimination of private insurance costs." 
 
 Sanders said he planned to take the bill on the road to "every state in the country and hear what the people have to say" for a roving national workshop. But the outreach came with a warning. He fired a shot across the bow of Republicans likely to oppose the bill, saying the GOP had "no credibility on the issue of health care." 
 
 "To my Republican colleagues, please don't lecture us on health care," Sanders roared to applause from the dozens of activists in the room. "In the last few months, you, the Republican Party have shown the American people what you stand for" by largely voting to dismantle Obamacare. 
 
 Taking her turn, Massachusetts Sen. Elizabeth Warren framed the push for single payer as the latest step in a long liberal project to expand access to medical care -- from Franklin Roosevelt's social security to Medicare and Medicaid under Lyndon Johnson and, most recently, Barack Obama's signature legislation. 
 
 "But we are here today to take another step," she said. "We will not back down in our protection of the Affordable Care Act, we will defend it at every turn, but we will go further -- we will go further and we will say that in this country, everyone gets the right to basic health care." 
 
 Before Sanders' remarks, supporters shared personal, often visceral accounts of doctors currently struggling to provide care and patients in need. An oncology nurse drew gasps in the room as she recounted the story of a cancer patient who could not afford to continuously empty the fluid building up in her lungs. The price of drainage bags, she said, was only covered in part by insurance, forcing the woman to ration her use. 
 
 The legislation unveiled on Wednesday afternoon in Washington arrived a little more than six weeks after the party's all-hands fight to preserve Obamacare secured a narrow reprieve on the Senate floor . Sanders' plan, though dead-on-arrival in a Republican-controlled Congress, offers a blueprint for fundamentally reshaping the American health care system by moving the country to a government-run, single-payer program. 
 
 Under Sanders' proposal, Americans would receive a "Universal Medicare card" that would be a ticket to comprehensive health care services, including hospital stays, doctor visits, substance abuse treatment, dental, vision and reproductive care -- including abortion. 
 
 However, consumers may have to pay up to $250 out-of-pocket for prescription drugs, with incentives to use generic medications. Sanders, who's been vocal about lowering drug prices, would allow the government to negotiate with pharmaceutical companies. 
 
 Long-term care, which Sanders had included in the version he unveiled during his presidential campaign last year, will not be covered. It will be addressed in separate legislation, an adviser to Sanders told CNN. 
 
 The bill calls for the elimination of premiums for private health insurance, deductibles and co-pays. However, most Americans and businesses will pay what Sanders says is a much smaller share of their income to fund the program. 
 
 While the new legislation has not yet been scored, the program Sanders pitched on the campaign trail came with an estimated annual price tag of nearly $1.4 trillion, to be paid for in part by a proposed new 2.2% income tax on all Americans, a 6.2% levy on employers and a further round of tax hikes on the wealthy. 
 
 California Sen. Kamala Harris made the business-friendly case for single-payer. (Or, as one leftist activist in the room grumbled afterward, "the neoliberal case.") 
 
 "Let's give the taxpayer of the United States a better return on their investment," she said. "Why? Because 'Medicare for all' stands for the proposition that all Americans from the day of birth, throughout their lives, will have access to health care." 
 
 The talk on Wednesday was broad, with little mention of the financial mechanics needed to propel such a massive program. But Sanders' plan does address one of the stickier questions facing such proposals: how to phase out the current system, which depends primarily on employer-sponsored private plans, without creating a disruption in care. 
 
 The answer, according to this new version of the bill, is to roll it out over a four-year transition period, a process Gillibrand and her office had a big hand in crafting. 
 
 The law would beef up Medicare -- adding dental, vision and hearing aid coverage -- in its first year, while reducing the eligibility age to 55. Children, up to age 18, would also be offered immediate access to the government-run plan. Over the next two years, the Medicare age would drop to 45, then 35 years old. By the fourth year, everyone would be eligible. 
 
 Despite the considerable legislative obstacles in its way, single-payer as a concept is gaining traction among the public. Some 53% of Americans support a national health care plan , according to a June poll by the Kaiser Family Foundation. That's up from 50% last year and from 40% between 1998 and 2000. 
 
 It is also notably increasing in popularity with some of the most ambitious Democratic officeholders -- a group of Senators possibly looking to run for the party's presidential nomination in 2020. 
 
 Harris was the first to announce plans to cosponsor the bill, followed by Warren. New Jersey Sen. Cory Booker and Gillibrand made their plans public on Monday and Tuesday. The names, some expected, others less so, rolled in right up to a few hours before the event, when New Hampshire Sen. Jeanne Shaheen announced her support. 
 
 Notable absences, however, included Senate Minority Leader Chuck Schumer of New York, Ohio Sen. Sherrod Brown, California Sen. Dianne Feinstein and the party's 2016 vice presidential nominee, Virginia Sen. Tim Kaine. Of the latter three, all up for reelection in 2018, only Brown is expected to face a serious Republican challenge. 
 
 Single-payer activists, mostly from the progressive grassroots movement that fueled Sanders' 2016 presidential campaign, are delighting in a sense of momentum after years stuck on the margins of the debate. 
 
 "This is an especially gratifying moment for the tens of thousands of nurses across the US who have dedicated years of effort to transform our health care system from an profiteering industry based on greed and suffering to patient need and healing," National Nurses United Executive Director RoseAnn DeMoro said in a statement. 
 
 She called the bill's introduction a "direct product of how Sen. Sanders made Medicare for all, and healthcare as a human right, such a signature issue of his campaign." ||||| Vermont Sen. Bernie Sanders and his call for a government-run health care system are back. On Wednesday, he is laying out a bill that proposes “Medicare for all,” replacing a U.S. health care system dominated by employer-provided insurance — with lots of assorted co-payments and deductibles — to a single-payer approach in which higher taxes fund a system where individuals don’t pay directly for health care. Influential Democratic senators and potential 2020 candidates Cory Booker (New Jersey), Kirsten Gillibrand (New York), Kamala Harris (California), Jeff Merkley (Oregon) and Elizabeth Warren (Massachusetts) have embraced the idea. 
 
 “Medicare for all” is going absolutely nowhere anytime soon under a Republican-controlled Congress and President Trump. But here’s the big question: Is it going to become one of the central goals of the Democratic Party and a defining feature of the campaign of whichever Democrat is the party’s nominee in 2020? This seems very likely, at least right now, given the political forces pulling Democrats to the left. But I’m not totally sure, mainly because there are some clear political and policy reasons for Democrats to avoid becoming the party of single-payer. 
 
 Why the Democratic nominee may have to strongly embrace Medicare-for-all 
 
 
 
 1. Some of the party’s most popular figures are already behind it. 
 
 FiveThirtyEight’s Nate Silver and Vox’s Matt Yglesias have argued that Sanders is, at least right now, the front-runner for the Democratic nomination for president. If Sanders, who is 76, opts not to run, the 68-year-old Warren seems like an obvious person for Sanders backers to embrace, as she shares many of the same liberal and populist positions. Harris, the daughter of an Indian woman and a Jamaican man, was elected district attorney in San Francisco and has won statewide election three times in California, which is about 40 percent Latino. A candidate with appeal to Asian, black and Latino voters as well as upper-income whites in cities like San Francisco would be formidable in a Democratic primary. I think it’s fair to say that all three of these senators would rank among the top 10 current contenders for the Democratic nomination. Booker is rumored to be considering a run as well. (The online betting site PredictIt ranks these four as among the top five people likely to get the Democratic nomination in 2020, along with former Vice President Joe Biden.) 
 
 So Booker, Harris, Sanders and Warren already being for Medicare-for-all greatly increases the chances of the Democratic nominee in 2020 supporting this policy, simply because one of that quartet has a strong chance of being the nominee. And staking out this position, well to the left of where the party was even last November, puts pressure on Biden, New York Gov. Andrew Cuomo and other Democrats who might be considering a 2020 run. Even if one of those candidates privately disagrees with the merits or the strategy of pushing Medicare-for-all, he or she might opt to support the idea to avoid being tagged as insufficiently liberal and therefore out of step with the party’s activist base. 
 
 This is how presidential nomination processes often work. In the campaign for the 2008 Democratic nomination, John Edwards came out with a comprehensive health insurance plan, effectively forcing Barack Obama and Hillary Clinton to do the same. (The Edwards plan, with its individual mandate and emphasis on creating health insurance marketplaces, was one of the building blocks of what eventually became the Affordable Care Act.) 
 
 This intra-party competition is the biggest and clearest reason to assume Medicare-for-all will become party dogma. 
 
 2. The Democrats are becoming a more liberal party. 
 
 In 2012, according to the Pew Research Center, about 19 percent of self-described Democrats considered themselves conservative, about 36 percent said they were liberal, and about 41 percent said moderate. Today, a plurality of Democrats (48 percent) describe themselves as liberal. A shift to Medicare-for-all would be in line with this march to the left. 
 
 And the party’s elected officials are headed there, too. The new “Better Deal” agenda that congressional Democrats unveiled in July includes a number of Sanders-inspired populist ideas. The party rebranding effort, for example, calls for requiring prescription drug companies to submit an explanation to the U.S. government if they increase the price of a drug by too much. 
 
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 In this environment, it is much easier to see a centrist Democrat like Cuomo essentially accepting Medicare-for-all as a stance he must take rather than pushing Democratic activists away from Medicare-for-all. 
 
 3. The Obamacare experience is moving Democrats. 
 
 In 2009 and 2010, when he was stumping for the Affordable Care Act, Obama often highlighted the private marketplaces that would be set up under the law. He mentioned how the ACA would expand Medicaid less often, perhaps with an eye on winning over more independent or conservative-leaning voters who might be leery of more government intervention in the health care system. 
 
 But in practice, the private marketplaces have been beset with high rates and insurers fleeing the system, while Medicaid expansion has been popular. This year, as Republicans sought to repeal the ACA, Democrats hammered them on Medicaid, which would have been cut by billions of dollars in the GOP repeal proposals. This defense of Medicaid by Democrats seemed to force even Republican senators like Nevada’s Dean Heller to say they were committed to defending the program. 
 
 “One thing has saved the Affordable Care Act from Republicans’ efforts to repeal it: When the votes counted, at least three Republican senators — along with every Democrat in the Senate — could not accept massive cuts to Medicaid,” wrote Mark Schmitt, who runs the Political Reform program at the D.C.-based think tank New America and was a longtime Democratic staffer on Capitol Hill. 
 
 Putting more people on government-funded health care programs is an idea that Democrats often favor but sometimes sidestep because they think it is too politically difficult to get adopted. (Obama, in an interview with Vox in January, essentially said that he thought a single-payer system would be more effective, but didn’t think it was possible to get that passed in 2009 or 2010.) The ACA experience has led Democrats — even those who strongly promoted and defended Obamacare — to argue that the ACA has not fixed enough of the country’s health care problems and push for a more comprehensive solution. 
 
 Party officials now believe that the public may be open to such a proposal. “It’s always the biggest applause line,” U.S. Rep. John Yarmuth of Kentucky, a Democrat, told me. 
 
 Warren, in a blog post on her website, carefully praised the achievement at the center of Obama’s legacy while signaling a desire to move beyond it, writing: “We owe a huge debt to President Obama. Because of the Affordable Care Act, health care coverage is better. … But there’s so much more we could do right now to bring down the costs of quality health care for every American.” 
 
 Why the Democratic nominee may be not strongly for Medicare-for-all. 
 
 
 
 1. A Medicare-for-all candidate may not win the primary. 
 
 There was a lot of talk in 2013 about how the Republican presidential nominee three years later would be more liberal on immigration issues than past candidates because of how badly Republicans did in the 2012 election with non-white voters. One of the people pushing that way on immigration (Marco Rubio) also seemed a likely top-tier presidential candidate, the way Booker, Harris, Sanders and Warren are. We know how that turned out. 
 
 Some combination of Booker, Harris, Sanders and Warren may not run for president. They might all run and lose. And the candidate who wins the Democratic nomination could be someone who breaks from the Medicare-for-all view, or at least says that he or she is open to other ideas to improve America’s health care system. Maybe that will be a figure like Biden or Colorado Gov. John Hickenlooper, either of whom might run for president and could position themselves as the center-left alternative to the more liberal candidates. In fact … 
 
 2. Medicare-for-all is not the only way to expand government-run health insurance. 
 
 Liberal wonks, such as Paul Krugman, are not so sure about Medicare-for-all. They argue that such a system is actually extremely complicated to create and that the final product might irritate the millions of Americans who have insurance through their employer and like it. 
 
 So some Democrats are proposing ideas like Medicare-for-some (U.S Sen. Chris Murphy of Connecticut) or Medicaid-for-some (U.S. Sen. Brian Schatz of Hawaii). The general idea is that people who are uninsured could buy (or be enrolled for little cost if they don’t make much money) into these programs. 
 
 This kind of a policy would be less of a shift to the left. Obama proposed a “public option” in 2009 that would have been similar to the ideas of buying into Medicare or Medicaid that Murphy and Schatz are touting. He dropped the idea after some more conservative Democrats opposed it, but by the end of his presidency, Obama had strongly embraced the idea. Hillary Clinton included a public option in her 2016 platform, though it was not a big feature of her campaign. 
 
 Maybe a more moderate Democrat could campaign on expanded Medicaid and Medicare but downplay the “for all” part. And that might have appeal because … 
 
 3. Many Democratic voters are not liberal. 
 
 I described earlier how liberals are ascendant in the Democratic Party. But according to Pew, the combined group of self-identified moderates (36 percent) and conservatives (15 percent) is as large as the liberals. Whites, people with college degrees, and millennials are disproportionately liberal, while other demographics in the party are not. According to Pew, 55 percent of white Democrats consider themselves liberal, compared with 28 percent of black Democrats and 41 percent of Latinos. About 60 percent of Democrats with postgraduate degrees consider themselves liberals, compared with about 37 percent of Democrats with a high school degree or less. 
 
 You could imagine New Orleans Mayor Mitch Landrieu pitching himself as the candidate who can appeal to working-class whites and more moderate Democrats. And part of that pitch could be running on a health care plan that is more likely to be passed into law than Medicare-for-all. 
 
 In June, Pew polled Americans on creating a “single-payer” health care system. Only 33 percent of the public overall supported the idea, although 52 percent of Democrats backed it. I assume Democratic support for Medicare-for-all will grow with more leading figures in the party embracing it. Also, the poll asked people about a single national health insurance system run by the government, not “Medicare-for-all,” which I suspect is a much more popular notion. But the survey did not ask respondents about “Medicare-for-all” versus “Medicare-for-some,” which might also be a popular idea. So public opinion on this issue could well shift in a number of directions. 
 
 I’m inclined to think that whoever receives the Democratic nomination in 2020 will support Medicare-for-all, either because he or she truly believes in the idea or because party politics effectively force this. I’m not so sure that this idea will ever become U.S. policy — or even come to a vote in Congress. But its embrace by Booker, Harris and Warren less than a year after the election tells us two important things about American politics right now: Sanders lost the Democratic Party’s nomination, but he may have emerged as the party’s intellectual leader. And the Democrats appear to have concluded from 2016 that, at least on economic issues, they should move left, not right. ||||| Hillary Clinton has made a lot of bad arguments about Bernie Sanders's support for single-payer. But her best argument was her simplest: With mere weeks to go before the Iowa caucuses, Sanders still hadn't released any details about his plan. And absent a real plan, no one could really say what he was proposing or whether it was a good idea. As Clinton said in an interview with MSNBC's Rachel Maddow, "The devil's in the details when it comes to health care." 
 
 On Sunday night, mere hours before the fourth Democratic debate, Sanders tried to head off Clinton's attacks by releasing his plan. Only what he released isn't a plan. It is, to be generous, a gesture toward a future plan. 
 
 To be less generous — but perhaps more accurate — this is a document that lets Sanders say he has a plan, but doesn't answer the most important questions about how his plan would work or what it would mean for most Americans. Sanders is detailed and specific in response to the three main attacks Clinton has launched, but is vague or unrealistic on virtually every other issue. The result is that he answers Clinton's criticisms while raising much more profound questions about his own ideas. 
 
 Sanders promises his health care system will cover pretty much everything while costing the average American almost nothing, and he relies mainly on vague "administrative" savings and massive taxes on the rich to make up the difference. It's everything critics fear a single-payer plan would be, and it lacks the kind of engagement with the problems of single-payer health systems necessary to win over skeptics. 
 
 What Sanders's plan tells us that we didn't know before 
 
 Clinton's first attack was that Sanders hadn't released a plan. Now he has. 
 
 Clinton's second attack was that Sanders would rely on states to manage and partially finance his health care system, as he's proposed in the past. His plan puts that criticism completely to rest, clarifying that the system will be "federally administered." As far as this document goes, there is no role for states at all. 
 
 Clinton's third attack was that Sanders's plan would raise taxes on the middle class. In response, Sanders gets very detailed on the financing of his plan. It would raise taxes on the middle class — in part through a 2.2 percent tax increase on all income, and in part by a 6.2 percent "income-based premium" on employers (which would, in turn, get passed on to workers through lower wages and higher prices). 
 
 The rest of the financing would come through a raft of new taxes on the rich. Sanders would raise marginal rates on income over $250,000, he would raise the tax rate on capital gains and dividend income, he would hike the estate tax, and he would close sundry deductions and loopholes. 
 
 In general, I'm comfortable with higher taxes on the rich — though they've risen substantially in the Obama era already — but tax increases of the scale Sanders proposes here would begin to have real economic drawbacks. European countries tend to pay for their health care systems through more broad-based, economically efficient taxes like VATs; Sanders's effort to fund a universal health care system so heavily on the backs of the wealthy would be unprecedented. 
 
 All in all, Sanders wants to raise taxes by a bit more than a trillion dollars per year — which may not sound like much to those who remember the Obamacare debate, but remember that the numbers that got thrown around for Obamacare were 10-year estimates. Adding inflation, Sanders will be raising taxes by close to $15 trillion when the Congressional Budget Office applies its normal scoring window. 
 
 Of course, these new taxes replace the premiums Americans pay now. Here, Sanders promises that between shifting health care financing to the rich and cutting costs through single-payer's efficiencies, his plan will only cost the average American family around $450 — a savings of more than $5,800 over what they're paying in premiums now. 
 
 Those benefits are big. To get them, Sanders is assuming some immense cost savings. And that's where the problems start. 
 
 Sanders's plan isn't Medicare for all 
 
 Sanders calls his plan "Medicare for all." But it actually has nothing to do with Medicare. He's not simply expanding Medicare coverage to the broader population — he makes that clear when he says his plan means "no more copays, no more deductibles"; Medicare includes copays and deductibles. The list of what Sanders's plan would cover far exceeds what Medicare offers, suggesting, more or less, that pretty much everything will be covered, under all circumstances. 
 
 Bernie's plan will cover the entire continuum of health care, from inpatient to outpatient care; preventive to emergency care; primary care to specialty care, including long-term and palliative care; vision, hearing and oral health care; mental health and substance abuse services; as well as prescription medications, medical equipment, supplies, diagnostics and treatments. Patients will be able to choose a health care provider without worrying about whether that provider is in-network and will be able to get the care they need without having to read any fine print or trying to figure out how they can afford the out-of-pocket costs. 
 
 Sanders goes on to say that his plan means "no more fighting with insurance companies when they fail to pay for charges." 
 
 To be generous, it's possible that Sanders is just being cynical in his wording, and what he means is that under his plan, individuals have to fight with the government rather than private insurers when their claims are denied. 
 
 But the implication to most people, I think, is that claim denials will be a thing of the past — a statement that belies the fights patients have every day with public insurers like Medicare and Medicaid, to say nothing of the fights that go on in the Canadian, German, or British health care systems. 
 
 What makes that so irresponsible is that it stands in flagrant contradiction to the way single-payer plans actually work — and the way Sanders's plan will have to work if its numbers are going to add up. 
 
 Behind Sanders's calculations, for both how much his plan will cost and how much Americans will benefit, lurk extremely optimistic promises about how much money single-payer will save. And those promises can only come true if the government starts saying no quite a lot — in ways that will make people very, very angry. 
 
 What Sanders doesn't tell us that we really need to know 
 
 "They assumed $10 trillion in health care savings over 10 years," says Larry Levitt, vice president at the Kaiser Family Foundation. "That’s tremendously aggressive cost containment, even after you take the administrative savings into account." 
 
 The real way single-payer systems save money isn't through cutting administrative costs. It's through cutting reimbursements to doctors, hospitals, drug companies, and device companies. And Sanders gestures toward this truth in his plan, saying that "the government will finally have the ability to stand up to drug companies and negotiate fair prices for the American people collectively." 
 
 But to get those savings, the government needs to be willing to say no when doctors, hospitals, drug companies, and device companies refuse to meet their prices, and that means the government needs to be willing to say no to people who want those treatments. If the government can't do that — if Sanders is going to stick to the spirit of "no more fighting with insurance companies when they fail to pay for charges" — then it won't be able to control costs. 
 
 The issue of how often the government says no leads to all sorts of other key questions — questions Sanders is silent on. For instance, who decides when the government says no? Will there be a cost-effectiveness council, like Britain's National Institute for Health and Care Excellence? Or will the government basically have to cover every treatment that can be proven beneficial, as is true for Medicare now? What will the appeals process be like? 
 
 This might sound technical, but it's absolutely critical. Sanders implies everything will be covered because he knows how important that question is to people. But everything won't be covered. So who decides, how do they decide, what gets covered, and what doesn't? Without knowing that, it's impossible to say whether a particular single-payer system is a good idea or a really, really bad one. 
 
 Another crucial question is whether Sanders envisions the possibility of exit inside his system. Technically, a single-payer system is a system with, well, a single payer. Private insurers are outlawed — otherwise, it would be a multi-payer system. But the term is often used more loosely than that, and many systems that get mentioned during discussions of single-payer, like the French system, include various kinds of supplementary, private insurance that people generally purchase. 
 
 The role of private insurers matters because it drives the government's bargaining power. If drug companies either sell to the government or they go out of business, then the government can get better prices. The problem there is obvious, though: What do people do if the government doesn't cover a treatment they need? But if there are private insurers selling add-on policies to wealthier Americans, then drug companies can deal only with them, and the government's negotiating power wanes. 
 
 Another question Sanders's plan doesn't answer but is crucially important: How do you guarantee physical access to medical care? Right now hospitals charge Medicaid one price, Medicare a somewhat higher price, and private insurers an even higher price. If the entire system is squeezed down to Medicare pricing, a lot of hospitals are going to close. How will Sanders keep that from happening? Or will he let it happen, even if it means people in rural areas need to drive hours for care? 
 
 The easy rejoinder to this is that this is just a campaign proposal, and these are details that can be worked out in the legislative process. I disagree. Sanders is proposing a huge, disruptive reform here — he owes the public answers to the most central, obvious questions about how that reform would work. Perhaps more importantly, he also needs to show that he's at least aware of the difficulties of a single-payer system and has realistic ideas for managing the transition. 
 
 Moreover, the fundamental debate between Sanders and Hillary Clinton — and Sanders and the GOP — is whether single-payer is a good idea at all. That debate can't be resolved unless these kinds of questions are answered. 
 
 In the absence of these kinds of specifics, Sanders has offered a puppies-and-rainbows approach to single-payer — he promises his plan will cover everything while costing the average family almost nothing. This is what Republicans fear liberals truly believe: that they can deliver expansive, unlimited benefits to the vast majority of Americans by stacking increasingly implausible, and economically harmful, taxes on the rich. Sanders is proving them right. 
 
 A few days ago, I criticized Hillary Clinton for not leveling with the American people. She seemed, I wrote, "scared to tell voters what she really thinks for fear they'll disagree." Here, Sanders shows he doesn't trust voters either. Rather than making the trade-offs of a single-payer plan clear, he's obscured them further. In answering Clinton's criticisms, he's raised real concerns about the plausibility of his own ideas. ||||| Sen. Bernie Sanders (I-VT) will release a proposal Wednesday afternoon to transition the United States to a single-payer health care system, one where a single government-run plan provides insurance coverage to all Americans. 
 
 The Sanders plan envisions a future in which all Americans have health coverage and pay nothing out of pocket when they visit the doctor. His plan, the Medicare for All Act, describes a benefit package that is more generous than what other single-payer countries, like Canada, currently offer their residents. 
 
 The Sanders plan goes into great detail about the type of coverage Americans would receive. But it provides no information on how it would finance such a generous health care system. Americans’ taxes would have to change to pay for this kind of proposal. But it’s impossible to tell who would pay significantly more for their coverage and who would pay less, and by how much. This is a crucial part of any health care plan, and in the Sanders proposal, it is notably absent. 
 
 So while the plan would certainly move the American uninsured rate from around 8.8 percent to nearly zero in theory, it’s impossible to tell what it would take to get there and what the bigger economic picture would look like if we did. 
 
 The Sanders bill includes an exceptionally generous benefit package 
 
 Sanders’s single-payer proposal would create a universal Medicare program that covers all American residents in one government-run health plan. 
 
 It would bar employers from offering separate plans that compete with this new, government-run option. It would sunset Medicare and Medicaid, transitioning their enrollees into the new universal plan. It would, however, allow two existing health systems to continue to operate as they do now: the Veterans Affairs health system and the Indian Health Services. 
 
 Those who do qualify for the new universal Medicare plan would get four years to transition into the new coverage. In the interim, they would have the option to buy into Medicare or another publicly run option that does not currently exist. 
 
 Eventually, though, they would all end up in the same plan, which includes an especially robust set of benefits. It would cover hospital visits, primary care, medical devices, lab services, maternity care, and prescription drugs as well as vision and dental benefits. 
 
 The plan is significantly more generous than the single-payer plans run by America’s peer countries. The Canadian health care system, for example, does not cover vision or dental care, prescription drugs, rehabilitative services, or home health services. Instead, two-thirds of Canadians take out private insurance policies to cover these benefits. The Netherlands has a similar set of benefits (it also excludes dental and vision care), as does Australia. 
 
 What’s more, the Sanders plan does not subject consumers to any out-of-pocket spending on health aside from prescriptions drugs. This means there would be no charge when you go to the doctor, no copayments when you visit the emergency room. All those services would be covered fully by the universal Medicare plan. 
 
 This too is out of line with international single-payer systems, which often require some payment for seeking most services. Taiwan’s single-payer system charges patients when they visit the doctor or the hospital (although it includes an exemption for low-income patients). In Australia, people pay 15 percent of the cost of their visit with any specialty doctor. 
 
 The Sanders plan is more generous than the plans Americans currently receive at work too. Most employer-sponsored plans last year had a deductible of more than $1,000. It is more generous than the current Medicare program, which covers Americans over 65 and has seniors pay 20 percent of their doctor visit costs even after they meet their deductibles. 
 
 Medicare, employer coverage, and these other countries show that nearly every insurance scheme we’re familiar with covers a smaller set of benefits with more out-of-pocket spending on the part of citizens. Private insurance plans often spring up to fill these gaps (in Canada, for example, vision and dental insurance is often sponsored by employers, much like in the United States). 
 
 The reason they went this way is clear: It’s cheaper to run a health plan with fewer benefits. The plan Sanders proposes has no analogue among the single-payer systems that currently exist. By covering a more comprehensive set of benefits and asking no cost sharing of enrollees, it is likely to cost the government significantly more than programs other countries have adopted. 
 
 Would Sanders’s health plan lower American health spending? It’s hard to tell. 
 
 One of Sanders’s main arguments in favor of his health care bill is that American health spending is out of control and single-payer would rein it in. 
 
 There are certainly policies in the Sanders plan that would reduce American health care spending. For one, moving all Americans on to one health plan would reduce the administrative waste in our health care system in the long run. 
 
 American doctors spend lots of money dealing with insurers because there are thousands of them, each negotiating their own rate with every hospital and doctor. An appendectomy, for example, can cost anywhere from $1,529 to $186,955, depending on how good of a deal an insurer can get from a hospital. 
 
 That doesn’t happen in a single-payer system like the one Sanders proposes. Instead of dealing with dozens of insurers that set hundreds of prices, doctors only need to send bills to the federal government. 
 
 One 2003 article in the New England Journal of Medicine estimates that the United States spends twice as much on administrative costs as Canada. A 2011 study in the journal Health Affairs estimates American doctors spend four times as much dealing with insurance companies compared with Canada. 
 
 A single-payer health plan would have the authority to set one price for each service; an appendectomy, for example, would no longer vary so wildly from one hospital to another. Instead, the Sanders plan envisions using current Medicare rates as the new standard price for medical services in the United States. 
 
 Medicare typically has lower prices than those charged by private insurance plans that cover Americans under 65. This suggests that switching to the Medicare fee schedule would be another policy change that would tug health spending downward. 
 
 But there are forces in the Sanders plan that encourage higher health spending too. Its robust benefit package with no cost sharing would likely lead to more doctor visits and hospital trips. As the classic RAND Health Insurance Experiment found, patients respond to lower cost sharing in health care by seeking more treatment. Some of that treatment is necessary, but other services provided are not. 
 
 And the Sanders bill would actually raise the prices currently paid by Medicaid, which covers about 50 million low-income Americans. Medicaid traditionally pays lower prices than Medicare and private insurance. If these patients were absorbed into the universal Medicare plan, their doctors would be paid more each time they were seen. 
 
 We haven’t seen a Congressional Budget Office score of the Sanders plan yet — and it’s hard to know how these countervailing forces (some pushing health spending up and others forcing it down) would interact with one another to change overall health costs. 
 
 The big question Sanders doesn’t answer: how do you pay for it? 
 
 The Sanders plan goes into great detail on what kind of coverage a universal plan ought to offer. But it does not do any work explaining how to pay for such a generous benefit package. 
 
 A Sanders spokesperson said over email the office would release a set of financing options later Wednesday afternoon. 
 
 “There’s nobody who has all of the answers,” Sanders told my colleague Jeff Stein when asked about the financing of his health plan. “Nobody has all the answers. What I can say is we are going to be listing a number of revenue-raising proposals, which will generate more than enough money to pay for what we want to do.” 
 
 Eventually though, somebody will need to have those answers — and they’re not easy to find. 
 
 Financing the health care system that Sanders envisions is an immense challenge. About half of the countries that attempt to build single-payer systems fail. That’s Harvard health economist William Hsiao’s estimate after working with about 10 governments in the past two decades. Whether he is in Taiwan, Cyprus, or Vermont, the process is roughly the same: Meet with legislators, draw up a plan, write legislation. Only half of those bills actually become law. The part where it collapses is, inevitably, when the country has to pay for it. 
 
 This is what happened when Sanders’s home state of Vermont attempted to create a single-payer plan in 2014. Much like Sanders, local legislators outlined a clear vision of the type of health plan they’d want to extend to all Vermonters. Their plan was arguably less ambitious; it did require patients to pay money when they went to the doctor. 
 
 But Vermont’s single-payer dream fell apart when the state figured out how much it would need to raise taxes to finance its new system. Vermont abandoned the government-run plan after finding it would need to increase payroll taxes by 11.5 percent and income tax by 9 percent. 
 
 It’s true — in Vermont and in the United States — that these increased taxes don’t necessarily mean overall health spending is rising. It’s entirely possible that health spending will go down as taxes go up, with Americans no longer spending billions on premiums for employer-sponsored coverage. 
 
 Single-payer systems change who pays for health care, often shifting more of the burden onto wealthier individuals to create a more progressive system. The proposed 9 percent income tax in Vermont, for example, would be far more expensive for the $100,000 worker than the $30,000 earner. 
 
 But who pays how much more is a key question this Sanders bill doesn’t answer. Until there is a version that does, we can’t know whether the health system the Vermont senator envisions could actually become reality. ||||| Bernie Sanders’ single-payer health care plan has won over most other liberal senators, including many weighing 2020 bids. 
 
 The rest of the Democratic Party is another matter. 
 
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 As Sanders prepares to unveil his Medicare for All legislation on Wednesday, most of the party’s congressional leaders and vulnerable Senate incumbents are steering clear. Even as the left celebrates Sanders’ ability to push the Democratic agenda leftward after his primary challenge to Hillary Clinton last year, that success appears to have its limits. 
 
 Senate Minority Leader Chuck Schumer told reporters that he would be “looking at all of” the party’s “many good” proposals to expand health care access, but declined to back Sanders. House Minority Leader Nancy Pelosi declared that her priority is shielding Obamacare from a GOP repeal push that’s not yet dead for good. 
 
 Connecticut Sen. Chris Murphy, one of the few Democrats subject to 2020 speculation who has not signed on to the Sanders bill, warned against letting the party’s attention slip to “longer-term health care policy” while the future of the Affordable Care Act remains up for debate. 
 
 “I think the risk is that we get distracted,” Murphy told reporters. “September’s not done. They can still ram through a repeal bill.” 
 
 Wisconsin Sen. Tammy Baldwin on Tuesday became the single-payer bill’s first supporter from the class of Senate Democrats up for reelection next year in states Trump carried. But other politically imperiled incumbent Democrats have said no to Sanders. 
 
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 Sen. Claire McCaskill said in a brief interview that lawmakers have more work to do to keep health care costs in check “before we would think about expanding that [Medicare] system to everyone.” 
 
 Single-payer on a national level would have “a lot of problems,” McCaskill added, although she came out in support of allowing individuals as young as 55 to buy into Medicare. That idea is also backed by Baldwin and two other red-state Democrats up for reelection next year who are declining to endorse Sanders’ bill: Sens. Sherrod Brown of Ohio and Debbie Stabenow of Michigan. 
 
 Stabenow, also a member of Democratic leadership, said Tuesday that she would keep working on her Medicare-at-55 plan “because I think there is some bipartisan interest in that.” She said the party’s first order of business should be shoring up the Obamacare markets, followed by other goals. 
 
 “The first thing has to be to protect the health care people have now and stabilize markets, no question,” Stabenow said. “But we need to focus on lowering the cost of prescription drugs and providing more health care, more health care options.” 
 
 Improving the Affordable Care Act is the core of a bipartisan effort in the Senate health committee. The panel's ranking member, Sen. Patty Murray of Washington, a member of the Democratic leadership, also declined to endorse Sanders’ bill on Tuesday. 
 
 “There’s a lot of Democratic ideas out there, and I haven’t had the chance to look at all of them,” Murray said, adding that she remains “very focused” on the committee’s work. 
 
 Republicans have already seized on the high costs of imposing a single-payer system — which Sanders’ presidential campaign proposed to pay for with new taxes on employers and wealthy individuals — to hammer Democrats for supporting the idea. The National Republican Senatorial Committee criticized Baldwin on Tuesday for backing “the left’s radical plans for government-run health care.” 
 
 Sen. John Barrasso (R-Wyo.), a member of GOP leadership, also reminded reporters Tuesday that Sanders’ home state of Vermont had to back away from its own single-payer health proposal after the economic burden proved too onerous. 
 
 Backers of the Sanders bill acknowledge that single-payer is a heavy political lift but describe it as an important benchmark for Democrats’ future. As the party hones its identity beyond opposition to Trump’s agenda, single-payer fans see enough room to set big long-term goals while waging the shorter-term battle to protect Obamacare. 
 
 “There’s nothing about the politics of the moment or the Affordable Care Act that in any way precludes supporting Medicare-for-all as the ultimate goal, and there’s a clear path to it,” said Sen. Richard Blumenthal. The Connecticut Democrat signed on to the bill Tuesday. 
 
 Sen. Al Franken (D-Minn.), who has been mentioned as a possible 2020 candidate, also expects to sign on to the single-payer bill, a spokesman said Tuesday. Franken noted that his cosponsorship reflects the bill's status as a long-term goal while the party continues short-term work on Obamacare. 
 
 "This bill is aspirational, and I’m hopeful that it can serve as a starting point for where we need to go as a country," Franken said in a statement. "In the short term, however, I strongly believe we must pursue bipartisan policies that improve our current health care system for all Americans — and that’s exactly what we’re doing right now in the Senate Health Committee, on which both Senator Sanders and I sit." 
 
 For other Democrats, however, the idea’s time may have not yet come. 
 
 Ben Cardin said in an interview that he supports universal health coverage but has "certain concerns" about using single-payer to achieve that goal. 
 
 “There’s the political issue, but there’s also the issue about how you make sure there will be adequate resources put into health care,” the Maryland Democrat said. 
 
 Sen. Joe Manchin of West Virginia, a member of leadership who's among the GOP's top targets in 2018, walked a fine line Tuesday as Republicans revived his past comments welcoming a discussion of a government-run health care system. 
 
 "I am skeptical that single-payer is the right solution, but I believe that the Senate should carefully consider all of the options through regular order so that we can fully understand the impacts of these ideas on both our people and our economy," Manchin said in a statement on Tuesday. 
 
 Sen. Dianne Feinstein, facing consternation from liberals in her home state of California — where an effort to enact single-payer statewide ran aground this year — said that she would want to see the price tag before taking a position on Sanders' bill. 
 
 "My understanding is, the cost of single-payer is enormous," Feinstein said, noting that she supports a public option for health insurance outside the private market. 
 
 Murphy and Hawaii Sen. Brian Schatz have offered their own ideas to shift the party's health care debate leftward without going as far as Sanders' plan would. The Connecticut Democrat is working on legislation creating a Medicare buy-in for all individuals and businesses, while Schatz told POLITICO he expects to release a Medicaid buy-in proposal later this month. 
 
 Murphy said he would not sign on to Sanders' bill before its release, urging "our party to take some time and look at all the options available to us before we decide on one unitary route." 
 
 And even as some Sanders-aligned activists spook Democrats with talk of possible primary challenges to candidates who don't support the single-payer plan, other liberals were content to cheer the Vermont independent for attracting more than one-quarter of the caucus to his legislation. Progressive Change Campaign Committee co-founder Adam Green, who worked with Murphy on the Medicare buy-in plan, said that "Democrats are increasingly wrapping themselves in the flag of" Medicare for all without closing off other options that advance the ball. 
 
 "This is how big ideas like expanding Social Security and debt-free college were moved into the mainstream — the North Star gets put up, solid organizing is done, critical mass is built in Congress and on the campaign trail, and party consensus falls into place," Green said by email. "It's happening now." ||||| (CNN) Progressives and Republicans have found something in common amid the raging health care debate: They all love talking about single-payer insurance. 
 
 No, they haven't bridged any of the divides on health care policy, and a Canadian-style single-payer plan -- the left prefers to call it "Medicare for all" -- remains implausible in the current Congress. 
 
 But both sides are beginning to see a political benefit in bringing it up. 
 
 Progressives have long held universal health care as a marquee public policy goal and increasingly see opportunities to push for a radical overhaul as President Donald Trump and Republicans on Capitol Hill face headwinds in their efforts to roll back Obamacare. 
 
 Vermont Sen. Bernie Sanders, an independent, is readying a bill proposing a single-payer system, and is expected to file it once the Senate finishes considering the GOP effort to repeal and replace former President Barack Obama's signature law. And more Democratic senators are publicly endorsing such a system. 
 
 Last week, New York Sen. Kirsten Gillibrand, who began her career as a moderate "Blue Dog" member of the House, backed single-payer. Massachusetts Sen. Elizabeth Warren, meanwhile, told The Wall Street Journal, "now it's time for the next step. And the next step is single-payer." 
 
 For Republicans, the calculation is different, but simple: Obamacare is politically more popular than the legislation Republican leadership is pushing on Capitol Hill. The danger of undercutting many of its provisions, including barring insurance companies from rejecting customers or hiking rates due to pre-existing conditions, is clear. For senators from states that accepted and have benefited from Medicaid expansion under the law, the vote is even trickier. 
 
 But single-payer health insurance, or "Medicare for all," is a much more divisive proposition. A recent Pew Research Center poll found that while 52% of Democrats support it, that number drops to 33% when the field expands to include Republicans. 
 
 In the White House and on Capitol Hill, GOP officials are now floating the prospect of a single-payer future -- rather than the survival of Obamacare -- as the likely alternative to a successful repeal process. 
 
 "If we have to negotiate with Chuck Schumer and the Democrats, we're going to be looking down the barrel of a single-payer system because that's what they want to see happen," Sen. John Thune, R-South Dakota, said on "Fox News Sunday." 
 
 Trump's deputy press secretary Sarah Huckabee Sanders brought up single-payer health insurance -- without being asked -- at the White House press briefing on Thursday. 
 
 "The other bill out there that's gained the support of a majority of House Democrats is the Bernie Sanders single-payer plan that would cost the government $32 trillion over the next decades. One hundred and thirteen House Democrats, including the DNC vice chair, have signed on to this approach," she said, referring to Rep. Keith Ellison of Minnesota, the deputy chairman of the Democratic National Committee. 
 
 "The President believes that it's completely unaffordable and creates a one-size-fits-all government approach to health care," she said. "That bill and others like it on the other side that have been proposed are clearly deal-breakers." 
 
 Progressives are also seeking to make use of Obamacare's rising popularity -- and the threat of its undoing. After years spent criticizing the law from the left, they have rallied to protect it in the face of repeal. 
 
 "Right now the goal is defeat this terrible piece of (Republican) legislation and then regroup and go forward doing what every other major country on Earth does and (pass) Medicare for all," Sanders told CNN last week. Days earlier, he and organizers from MoveOn.org, the liberal advocacy group, were barnstorming Pennsylvania, Ohio and West Virginia, rallying opposition to the GOP bill. 
 
 But even as Sanders railed against Trump, tallied Obamacare's achievements and warned about the dangers facing those who might lose coverage, the mention of "Medicare for all" still triggered the heartiest outpouring of applause at already boisterous events. 
 
 "If Democrats retake power, the idea of a public option and Medicare for all are going to be a much easier sell because they stood shoulder-to-shoulder in the fight today," MoveOn's Washington director, Ben Wikler, said as protests swirled on Capitol Hill ahead of the July 4 recess. 
 
 The real test, though, will come when Sanders releases his new single-ayer bill later in the summer. 
 
 The 2011 edition had zero co-sponsors . This new legislation figures to arrive with more support from Democrats, including potential 2020 hopefuls like Gillibrand and Warren, and to greater fanfare from Republicans, who sense both opportunity and danger. 
 
 In both cases, the one sure bet is that both sides will be eager to chat about it. ||||| By dropping his healthcare plan so close to the debate, Sanders' campaign all but guarantees he will spar with Clinton on the topic on Sunday night. | Getty Sanders, Clinton clash over his new 'Medicare for All' plan 
 
 CHARLESTON, S.C. — Bernie Sanders released the details of his “Medicare for all” single-payer health care plan just two hours before the Democratic debate here on Sunday night, escalating the bitter wrangling over health care with Hillary Clinton. 
 
 “Universal health care is an idea that has been supported in the United States by Democratic presidents going back to Franklin Roosevelt and Harry Truman,” Sanders said in a statement as he unveiled the plan. “It is time for our country to join every other major industrialized nation on earth and guarantee health care to all citizens as a right, not a privilege." 
 
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 Clinton's campaign swiftly issued a critical statement, questioning Sanders' numbers and details, and Clinton during the debate hit him for switching up the details after she highlighted flaws in his earlier blueprints, particulary her contention that he left too much of it up to the states -- and their Republican governors. 
 
 But her main health care point during the debate itself was that Democrats should defend and improve Obamacare-- not "tear it up and start over" in a divisive debate over single payer. 
 
 "Here's what i believe," she said. "The Democratic Party and the United States worked since Harry Truman to get the Affordable Health Care Act passed. We finally have a path to universal health care. We have accomplished so much already, I do not to want see the Republicans repeal it and I don't to want see us start over again with a contentious debate." 
 
 Sanders denied he'd tear down Obamacare, noting that he had a role in drafting it and he voted for it. But he said he wants to build on it, and bring down the cost of health care which is still leaving the newly insured with big expenses. He also pointed out that nearly six years after Obamacare was enacted, around 29 million people are still uninsured. 
 
 He said the obstacles were the "campaign finance system that is corrupt," as well as insurers and the pharmaceutical industry "pouring hundreds of millions of dollars into campaign contributions and lobbying." 
 
 The Sanders' proposal released before the debate includes a series of tax increases, though the Vermont senator's campaign contends that it would save families and employers money once they transition to the government-financed system and no longer have to pay insurance premiums. 
 
 His plan calls for a federally- managed program paid for by a new 6.2 percent income-based health care tax paid for by employers, a new 2.2 percent income-based tax paid for by households, and a progressive tax scheme with a top rate of 52 percent for those earning over $10 million. 
 
 It also includes an estate tax which the campaign said would affect the wealthiest 0.3 percent of Americans. It also includes a proposal to tax capital gains the same as work income. 
 
 In a memo, Sanders’ campaign says it estimates that the plan would cost $1.38 trillion per year. 
 
 It will take health care economists some time to crunch his new numbers. But he's been attacked in the past for making overly optimistic estimates about how much savings his health plan could wring from the system to close spending gaps. 
 
 Clinton's campaign quickly fired off a statement criticizing Sanders for releasing the plan two hours before the debate and accusing the Vermont senator of shifting on core issues. Her campaign in particular faulted his earlier plans for allowing states to potentially undermine federal protections. 
 
 “Sen. Sanders has been changing a lot of positions in the last 24 hours because when his plans and record come under scrutiny, their very real flaws get exposed," campaign spokesman Brian Fallon said in the statement. "After digging in his heels for weeks, he backpedaled on his vote to give sweeping immunity to gun manufacturers and dealers. And after weeks of denying the legitimacy of the questions Hillary Clinton raised about flaws in the health care legislation he’s introduced 9 times over 20 years, he proposed a new plan two hours before the debate." 
 
 Sanders bristled at the criticism of his proposal's cost and possible burden on the middle class. "I'm disappointed that Secretary Clinton's campaign has made this criticism. It's a Republican criticism. Secretary Clinton does know a lot about health care, and she understands, I believe, that a Medicare-for-all, single-payer program will substantially lower the cost of health care for middle class families. 
 
 Many liberal Democrats have long championed a single-payer health plan, also known as Medicare for all. But even many of its advocates backed the Affordable Care Act as a more politically realistic strategy for expanding health coverage — and even that has been a nonstop political struggle. 
 
 Early versions of the health care bill in Congress in 2009 did include a scaled-back substitute for single payer, known as the public option, but it was jettisoned after centrist Democrats and insurers objected. Clinton noted that history during the debate Sunday night. 
 
 Sanders has fought back against the Clinton camp including Chelsea Clinton’s criticisms of his proposal as likely to “dismantle” the ACA, Medicare, and private insurance. 
 
 Some Sanders allies have noted Clinton's own disagreements with President Barack Obama over health policy in their 2008 primary fight, but Clinton's team has embraced the ACA and had put considerable pressure on Sanders to release his plan, turning health care into a central point of contention between the two candidates. ||||| Democrats are increasingly committing to support single-payer healthcare, amid Republican attacks on ObamaCare and pressure from their party’s left-wing base. 
 
 What was once considered only a progressive talking point has gained traction as more Democratic candidates have been willing to embrace government-funded healthcare on the campaign trail and more House members have been signing onto the idea. 
 
 Single-payer isn’t just being discussed in liberal enclaves of the country like California, where a single-payer measure recently fell short in the state Assembly. It’s a hot topic in Speaker Paul Ryan Paul Davis RyanOvernight Health Care: Trump calls for crackdown on surprise medical bills | Trump officials give religious exemption to foster care program | Uninsured rate at highest level since 2014 | Juul hires former Harry Reid chief of staff As new Congress begins, federal-state connections are as important as ever Trump once asked Paul Ryan why he couldn’t be ‘loyal': book MORE’s (R-Wis.) Republican-leaning district, where all the Democratic candidates running in the primary have supported it. 
 
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 The idea hasn’t won universal appeal in the party, but the spotlight has been shone on the concept of a government-run healthcare system as concerns mount over the Senate GOP’s plan to repeal and replace ObamaCare, which would lead to 22 million more Americans without insurance. 
 
 Sen. Bernie Sanders Bernard (Bernie) SandersSanders poised to announce presidential campaign: report On The Money: Trump agrees to end shutdown without wall funding | Senate quickly clears short-term funding measure | House to vote tonight | Federal workers could get back pay within days | Dems take victory lap Shutdown ends without funding for Trump’s border wall MORE (I-Vt.) championed the idea of universal healthcare during his insurgent presidential campaign, and he’ll introduce his single-payer plan once the debate over ObamaCare ends. 
 
 Other senators — such as Elizabeth Warren Elizabeth Ann WarrenSen. Warren misses the mark on the living wage debate RNC votes to give Trump 'undivided support' ahead of 2020 A crowded 2020 presidential primary field calls for ranked choice voting MORE (D-Mass.) and Kirsten Gillibrand Kirsten Elizabeth GillibrandRNC votes to give Trump 'undivided support' ahead of 2020 Hickenlooper 'leaning' toward joining 2020 race in next few weeks Poll: Biden leads among Dems in 2020 primary field MORE (D-N.Y.), two potential 2020 contenders — are getting on board with a Medicare for All proposal. Sen. Tammy Baldwin Tammy Suzanne BaldwinWhy does the bankruptcy code discriminate against disabled veterans? 116th Congress breaks records for women, minority lawmakers Kyrsten Sinema swears in to Congress using copy of Constitution instead of religious book MORE (D-Wis.), who faces a tough reelection in a state won by President Trump, said she’s a “maybe” on Sanders’s plan but “anticipates” supporting it, according to The Capital Times. 
 
 In the House, Rep. John Conyers Jr.’s (D-Mich.) Medicare for All bill has already netted 113 co-sponsors — nearly double the number of co-sponsors the legislation garnered last congressional session. 
 
 Key names are noticeably absent from the list, including House Minority Leader Nancy Pelosi (D-Calif.) and Minority Whip Steny Hoyer (D-Md.). But other members of leadership, including Democratic Caucus Chairman Joseph Crowley (D-N.Y.) and Assistant Democratic Leader James Clyburn (D-S.C.), are co-sponsors of the bill. 
 
 “It’s nice to see many senators … and a variety of people in the House publicly stating for the first time on record that a single-payer system is the way of the future that we need to be working toward,” Shannon Jackson, the executive director of the Sanders-aligned group Our Revolution, told The Hill. 
 
 Warren has publicly encouraged Democratic candidates to campaign on the idea in 2018 and 2020. But even though the Democrats in Ryan’s likely safe GOP district are supporting it, other Democratic candidates in red states and districts have been more cautious about endorsing single-payer. Rob Quist, the Montana Democrat endorsed by Sanders, was the only candidate in this year’s House special elections to run on that platform. 
 
 “I think that the politicians who choose to run on a campaign that states and embodies that pillar of our platform will be successful and they will be able to connect with the people,” Jackson said. 
 
 A Kaiser Family Foundation poll shows a modest increase in Americans’ support for the concept, with 53 percent of the public supporting all Americans getting their coverage through a single government plan. 
 
 That’s up from 2008 and 2009, when about 46 percent of the public held this position. A majority of the uptick in support has come from independents, Kaiser noted. 
 
 But in practice, Democrats haven’t been able to muster enough votes to pass a single-payer plan. In California’s state Assembly, moderate and progressive Democrats couldn’t agree on the proposal. While it passed the state Senate, California Assembly Speaker Anthony Rendon (D) ultimately tabled the proposal in his chamber. 
 
 “It’ll tend to be an issue that more left-leaning Democrats are willing to embrace,” said Dan Mendelson, president of consulting firm Avalere Health. 
 
 “In order to embrace that concept, you’ll have to be willing to defend the efficiency and effectiveness of a fully run government system, and there are many Democrats who are not going to do that and there are some who are.” 
 
 For Democrats, the increased talk about single-payer offers an alternative message to oppose the Senate GOP’s bill to repeal and replace ObamaCare, he said. 
 
 Under a single-payer system, all Americans would have health coverage, whereas the nonpartisan Congressional Budget Office estimates 22 million people would become uninsured under the Senate GOP’s healthcare plan. 
 
 “I think what you see is the Democrats on the Hill are searching for a single unifying message to unite in opposition to what is happening presently in the Congress,” Mendelson said. “And that’s really what they're looking for.” 
 
 Republicans have taken note, seizing on Warren’s request for Democrats to campaign on single-payer in an attempt to play offense in the healthcare debate as Republicans struggle with their unpopular plan. 
 
 But Republicans are seeing an advantage in Democrats’ embrace of single-payer, too. The National Republican Senatorial Committee (NRSC) is running auto-play Facebook ads that seek to tie the 10 Democratic senators up for reelection in states Trump won to Warren and government-run healthcare. 
 
 The Senate GOP’s campaign arm and the Republican National Committee have pointed to studies that say Medicare for All could cost as much as $32 trillion over a decade. 
 
 “I think that the idea that this is becoming our central focus is mistaken and one that our opponents are trying to put forward so they don’t have to talk about their age tax,” said a Democratic strategist with ties to Senate races. “What unites Senate Democrats is opposition to this disaster of a Republican bill.” 
 
 Some Republicans don’t see single-payer becoming a toxic issue for Democrats, arguing that those kinds of attacks are more of a “deflection tool” from the GOP’s own healthcare bill. 
 
 “It almost seems like it’s too wonky and not enough red meat to really make something catch fire,” a Republican operative in Washington told The Hill. “It’s hard to attack Democrats over single-payer healthcare when we can’t get our act together on repealing ObamaCare.” 
 
 Despite increasing talk of single-payer, Democrats haven’t agreed yet on a healthcare message for the 2018 midterms, in part because that will depend on whether Republicans manage to repeal ObamaCare. 
 
 "The [GOP] Senate bill is almost designed to make healthcare top-tier issue in the next elections,” said Larry Levitt, a Kaiser Family Foundation senior vice president. 
 
 “If the repeal and the replace bill is enacted and signed into law, Democrats will face a challenge as to what their healthcare message will be in 2018 and 2020,” Levitt said, adding that “it’s very likely that many Democrats would turn to single-payer as the next step.”
– Bernie Sanders rolled out his vision to overhaul the health care system on Wednesday, one in which everybody would get their insurance from the government through Medicare instead of through their jobs or a private insurer. Sanders calls it the Medicare for All Act of 2017, but you'll also hear phrases such as "single payer" and "universal health care" used to describe it. One key part missing: details on how to pay for it, though Sanders plans to release a separate paper on that, reports the Wall Street Journal. Coverage: The basics: Per CNN, everybody gets a "Universal Medicare card," which would be used to cover all health bills, from surgeries to dental care to substance abuse treatment. Co-payments would go away, and people would pay premiums based on their incomes, reports the AP. Private insurers would still exist, but for things such as elective plastic surgery or, sometimes, to act as middlemen between the government and hospitals or doctors. A 'right': Sanders makes his case in an op-ed in the New York Times. "Guaranteeing health care as a right is important to the American people not just from a moral and financial perspective; it also happens to be what the majority of the American people want." 'Single payer': David Leonhardt of the New York Times has a Q&A on the fundamentals, including the basic question of what the term "single payer" means. In short, it "describes a system in which only one entity—the government—pays medical bills. If all Americans had Medicare rather than insurance through their jobs, it would be a single-payer system." Vox says Sanders' system is far more generous than single-payer plans in Canada and elsewhere. The cost: This could cost hundreds of billions of dollars more per year, per the Journal. Details are yet to come, but Sanders envisions a progressive tax increase, with the wealthy paying more income, capital gains, and estate taxes, reports Newsweek. The senator says higher taxes for families would be offset by the fact that they no longer have to buy insurance. Still, in regard to single-payer systems, "no one—including Sanders—has truly reckoned with how to pay for whatever system they might support," writes Mike Allen at Axios. Litmus test? By all accounts, the chances of it passing a GOP-controlled Congress are precisely 0%. But it's turning into a political litmus test of sorts for Democrats, reports the Washington Post. Sanders has the support of 15 Democratic senators so far, including all of those seen as potential 2020 presidential candidates. Co-sponsors include Elizabeth Warren, Kirsten Gillibrand, Cory Booker, and Kamala Harris. But many prominent Democrats are not on board, at least yet, including Nancy Pelosi, Chuck Schumer, and those in tough re-election fights, reports Politico. The politics: No, this isn't going to pass, "but here's the big question," writes Perry Bacon Jr. at FiveThirtyEight. "Is it going to become one of the central goals of the Democratic Party and a defining feature of the campaign of whichever Democrat is the party's nominee in 2020?" As of now, this "seems very likely," as the Democratic party seems to be gravitating to the left. But Bacon lays out the political and policy reasons why Democrats might avoid "becoming the party of single payer." Relishing the fight: Republicans see a chance to pounce. "We welcome the Democrats' strategy of moving even further left," says Katie Martin, spokesperson for the Senate GOP's campaign organization, per the AP.