For the second Democratic presidential debate in a row, health care came up right away. And for the second debate in a row, what followed was a serious, substantive discussion that put the different perspectives of Bernie Sanders and Hillary Clinton into sharp relief.
In the end, their big dispute wasn't really over whether a single-payer system is a good idea in principle. It was whether such a system could actually work in the U.S.
To review: Sanders wants to create an entirely new health care system, replacing the current patchwork of private and public plans with one, government-run insurance program. The insurance he envisions would wipe out nearly all out-of-pocket spending, and give government more power to set prices, in order to hold down the cost of health care.
To finance this plan, Sanders would impose new taxes, some on the wealthy and some on the middle class. But the typical American would actually save money, Sanders says, because the new tax burden would be less than what the typical American now pays in private insurance premiums, deductibles, and co-pays.
Clinton prefers to build incrementally on the Affordable Care Act, which President Barack Obama signed into law six years ago and has now reduced the proportion of Americans without health insurance to about 10 percent. She has called for modestly improving protection from out-of-pocket costs and giving government more leverage with the prescription drug industry.
These are not major initiatives and Clinton has not specified how, exactly, she would get the country to 100 percent coverage -- something a single-payer plan would in theory achieve right away, because it would enroll people automatically. But Clinton has warned that creating a single-payer system would be highly disruptive, since it would mean changing everybody's insurance.
Clinton also has warned that Sanders’ plan would almost certainly cost a great deal more than Sanders says -- an argument with which most (but not all) well-known health policy experts agree. As a result, Clinton says, the number of people worse off after the transition could be much larger than Sanders has indicated.
The (somewhat) novel twist in Thursday’s discussion came in the sharp, but respectful back-and-forth that followed the initial question. In order to defend his claim about savings from single-payer, Sanders noted that every other country in the world manages to cover nearly all people while paying less -- and frequently far less -- than the U.S. does. He is absolutely correct about that. It's proof that, over the long haul, universal coverage doesn't require higher spending.
But Clinton had an answer ready: Most of those other countries built their universal coverage programs decades ago, as their health care systems were first evolving. It would be far more difficult to impose such a system on the existing U.S. health care infrastructure, she said.
To take one example: A plan like Sanders envisions would almost certainly require deep cuts in payments to hospitals. The hospitals would fight those cuts and, if somehow the cuts made it through Congress, many would probably suffer financially -- leading to shortages and closures. That would cause either hardship, a severe political backlash, or some combination of the two.
The plan that Sanders has sketched out will appeal to many voters. And while the systems abroad with single-payer have their pluses and minuses, overall they really do perform quite well.
But the transitional hazards that Clinton described are very real, and something that might give many Americans serious pause.
More coverage of the Democratic debate: