When the Affordable Care Act was being created in 2009, many liberals who weren’t too excited about the form it was taking hoped that eventually it could evolve into something more to their liking. They told themselves that the ACA’s reforms may have kept private health insurance central, but over time it could be modified to inch closer to the kind of universal system enjoyed by citizens of every other industrialized country.
Ironically, precisely because Republicans took over the government eight years later and began an attack on the ACA, we may get to that point a lot quicker than liberals anticipated.
Right now Democrats are coalescing around a new model for health-care reform. This November’s election could validate it in a way that practically settles the issue among Democrats. That will then determine the discussion in 2020, and in 2021 it could become the basis for a hugely ambitious overhaul of the system. Right now we could be witnessing the genesis of one of the most important domestic policy changes in our history.
What’s striking is how rapidly this is taking place, especially compared with the last time Democrats did this. After the failure of Bill Clinton’s attempt at health reform in 1994, Democratic health policy wonks began researching, analyzing and debating the issue to figure out what kind of different reform might address the system’s key problems while also being politically viable. It took years before they settled on the “three-legged stool”: Requiring insurance companies to cover everyone without regard to preexisting conditions, an individual mandate to get everyone into the system and subsidies to make sure everyone could afford insurance.
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Mitt Romney instituted a form of this in Massachusetts in 2006, and in the 2008 election, all the leading Democratic presidential candidates proposed something similar. There were certainly liberals who didn’t like it, but it was the direction the party collectively decided to go. With that mandate (and a Democratic Congress) in hand, Barack Obama made it one of his top domestic priorities, and it passed in 2010.
So: more than a decade of internal debate, which produced a basic consensus that eventually reached the party’s politicians, ultimately resulting in policy change, in a mere 16 years.
Now look where we are today. With Donald Trump’s victory and the ensuing assault on the ACA from the White House and Republicans, everything has changed. It’s been just 17 months since the election, and we have a completely new consensus among Democratic politicians.
A group of Democratic senators led by Jeff Merkley (Ore.) and Chris Murphy (Conn.) has introduced the Choose Medicare Act, which would open up Medicare to anyone who wants it and isn’t already eligible for Medicare or Medicaid. Individuals could get it through the exchanges and employers could put their employees on it instead of private insurance. In its basic structure, it’s extremely similar to the Medicare Extra For All plan put out by the Center for American Progress, the most influential liberal think tank. There’s also a plan to allow states to create a buy-in to Medicaid introduced by Sen. Brian Schatz (D-Hawaii) and Rep. Ben Ray Luján (D-N.M.), and a Medicare-X Choice Act from Sens. Michael Bennett (D-Colo.) and Tim Kaine (D-Va.). Sen. Bernie Sanders (I-Vt.) still has his Medicare for All plan, which differs from these in that they emphasize that it would be voluntary, and private insurance would stay around as long as it can compete.
These plans are not identical, and the details do matter — about how it’ll be structured, what will be covered, how it’ll be paid for, and so on. But the basic idea seems to have been decided. Here’s the most succinct summary I can offer:
Open up an existing government health insurance program, either Medicare or Medicaid, to anyone who wants it.
There’s an important caveat here. If you ask a health policy wonk, they’re likely to say, “Not so fast — there are a lot of questions we need to answer.” They may tell you that as important as expanding coverage is, the whole effort will be a failure if we can’t do something to bring down our health-care prices, which are the highest in the world. As Paul Starr of Princeton University and the American Prospect told me Thursday, “The differences among the various plans being offered are enormous; it’s just the rhetoric that’s similar.”
But even if we don’t have a consensus among Democratic policy wonks, we’re getting awfully close to a consensus among Democratic politicians, on that one basic idea.
That consensus is spreading to Democrats around the country. Your ordinary House candidate doesn’t usually come up with his or her own plan, so he or she looks around at what people in their party are proposing, pick something that sounds good to them and slot it into the “Issues” section of their web site. This helps determine what voters hear and what members of Congress feel they’ve committed to.
So right now there are future Democratic members of Congress who are saying to voters, “Let’s open up Medicare to anyone who wants it.” And it’s a hugely popular idea — 75 percent of Americans support it in this Kaiser Family Foundation poll. Those candidates will start polling the idea themselves, or look to Democratic messaging projects such as this one, which will probably reiterate for them that voters think it sounds like a great idea. People who remember how hard it was to explain the ACA to voters will be excited to have something to say on health care that’s easy to understand.
If Democrats take back the House, don’t be surprised if they pass one or more of these bills in 2019 or 2020, just as a demonstration. Then the party’s presidential candidates will all have plans that start with the idea of opening up Medicare or Medicaid, and if one of them wins, that will be the basis of the next attempt at health-care reform. Does that mean it will pass, or that we know exactly what it will look like? Not at all. But if the next Democratic president signs major health-care reform, it’s going to include opening up Medicare or Medicaid. And we’ll look back and say that it all started right now.
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