Offense and defense on health care
The Democratic presidential candidates have been engaged in a vigorous debate about whether, and how, to expand the federal government’s role in health care. It was issue No. 1 at this week’s debates in Detroit. The battle lines range from all in on Medicare for All (Bernie Sanders, Elizabeth Warren) to mostly in (Kamala Harris, Pete Buttigieg) to slightly in (Joe Biden) to warnings that such a radical change could doom the party’s chances in 2020 (John Hickenlooper, John Delaney, Michael Bennet).
Advocates of a singlepayer system were quick to dismiss any challenges of a singlepayer system — regarding cost, effects on already struggling hospitals, impact on the 150 million Americans with employerprovided coverage — as a “Republican talking point.” That phrase was invoked so often that it has become a favorite Democratic talking point.
But even as the Democrats argue about who is being bold and who is being pragmatic, the reality is that the party’s nominee will have quite a sales job in persuading Americans to change course a mere 10 years after President Obama’s signature domestic achievement, the Affordable Care Act, barely passed in a Democraticcontrolled Congress. The final House vote on Obamacare was 219212, without a single Republican vote.
Obamacare has since become more widely accepted by the public, and Republican threats to repeal it helped the Democrats regain the House in last year’s midterms.
As a political matter, the challenge will be to assure Americans who, time and again, have proved apprehensive about any change to their health care coverage — however flawed or expensive. A recent Kaiser Family Foundation Health Tracking Poll found that just 51% of the public now say they favor Medicare for All. What is telling about that number is it is down from 56% in April. The fact that Democrats are highlighting it in town halls, debates and interviews has not been moving the needle in the right direction, though Sanders and Warren remain in the top tier of the field.
For now, the argument is aspirational. Barring a shift of power in the Republicancontrolled Senate, Medicare for All would have little chance of passage. But it’s a debate worth having. The United States spends significantly more than other developed countries on health care even while trailing them in key indicators such as infant mortality and life expectancy.
However, lurking in the background is a legal challenge to Obamacare that could turn the issue from offense to defense for Democrats. A federal appeals court in New Orleans is considering arguments — supported by the Trump administration — that the ACA is unconstitutional. The case was filed by an alliance of red states after the Republican push to repeal the act collapsed in Congress. Attorneys general from blue states, including California, have put up a defense of the 2010 law that extended coverage to 20 million Americans and included such popular provisions as assurances that consumers could not be denied coverage because of a preexisting condition and dependents could stay on a parent’s plan until age 26.
Two of the panel’s three judges — both GOP appointees — appeared sympathetic to the challenge during oral arguments. The appeals court is expected to rule in the next few months, and the case likely will end up in a conservativemajority U.S. Supreme Court, with the prospect of a ruling in the heat of the 2020 campaign.
If the high court invalidates Obamacare, the political impact could be substantial — and unpredictable — as Americans face the prospect of losing the limited options they have.