POWERFUL TWISTS, TURNS
Ben Franklin may have been wiser than he knew. When he declared in 1789 that the only certainties in life were death and taxes, did he foresee that both would still be at the center of America’s politics 230 years hence, in the guise of our seemingly interminable debate over healthcare reform?
Healthcare was a dominant theme in the six Democratic presidential debates staged from June through December, and it’s a fair bet that it will continue to play a central role throughout the coming presidential election year. The reason is obvious: The issue touches everyone, regardless of race, creed, color or wealth.
The variations among the plans proposed by candidates Bernie Sanders, Elizabeth Warren, Joe Biden and Kamala Harris (who has already dropped out of the race) have been almost infinite and the proposals themselves, perhaps with the exception of Sanders’, fluid. Pundits have punished candidates for sticking with their initial proposals, or for backing off or doubling down.
Was Warren’s recent slide in opinion polls due to her original plan, or to her acknowledgment, via a “transition” proposal, that even under the most favorable political conditions the U.S. won’t be changing from its private insurance system to single payer in the blink of an eye, but only over a period of years? (In her proposal, Warren said she would reverse President Trump’s “sabotage of healthcare” while making Medicare free for children younger than 18 and low-income households, on the way to making government health coverage free to everyone by the end of her first term.)
The proposals have all revolved around a nebulous idea known as “Medicare for all.” To the extent that the candidates have faltered in their approaches, it’s because they’ve tried to define Medicare for all. At this stage, however, that’s impossible. Whatever reform program ultimately emerges, it will be the product of intense legislative compromise, with the input of myriad stakeholders — doctors, hospitals, drug companies, wheelchair makers, insurers and patient advocates.
Consequently, it’s best to think of Medicare for all as a binder holding the points that all the Democratic proposals share in common: universal coverage, the reduction or elimination of out-ofpocket costs such as deductibles and co-pays, the replacement of those costs and premiums by taxes and less spending overall.
How costs will be wrung out of the system and out of whose hide — caps on doctor fees? On hospital billing? On drug prices? — are impossible to pinpoint today. The more detail any candidates try to offer, the more they’re providing attack points for their adversaries.
What’s most important is that they recognize that there’s one real obstacle to crafting a fair, universal healthcare system like those enjoyed by residents of France, Germany and Britain, or even to preserving the reforms brought about through the Affordable Care Act. That’s Republican and conservative opposition.
Trump has tried systematically to erode the consumer protections created by the Affordable Care Act, including safeguarding access to coverage for people with preexisting medical conditions and guaranteeing that health insurance plans provide for a roll of “essential benefits” including maternity care, hospital coverage, prescription drugs and mental health and substance abuse treatment.
The Trump administration has taken steps to undercut that standard by expanding the availability of short-term health plans, which are cheaper than traditional Obamacare plans but don’t offer the full range of benefits and can reject applicants with preexisting conditions.
The most serious threat to the Affordable Care Act comes from a lawsuit brought by 20 red states seeking to overturn the law, on the grounds that Congress’ elimination of the individual mandate penalty rendered the law unconstitutional.
The conservative U.S. 5th Circuit Court of Appeals, in its ruling on that claim Dec. 18, invalidated the individual mandate as unconstitutional, but instructed a lower-court judge to decide whether other parts of the law could stand. No immediate change in the Affordable Care Act resulted, but the issue seems destined to reach the Supreme Court.
The Supreme Court has twice upheld the Affordable Care Act. Arguments in the case could possibly take place about the time of the November election.
As Franklin seemingly foretold, the healthcare debate will be with us well into the next year, and possibly beyond.