Health care was one of the key issues that drove the Democratic surge in last November’s elections, and as the new year begins, Democrats both in Congress and at the state level are wasting no time in moving to expand access to health coverage. As the saying goes, elections have consequences, and the consequences on this issue are shaping up to be pretty dramatic.

Let’s take a quick tour around:

  • Newly inaugurated Gov. Gavin Newsom (D-Calif.) released a plan that would unify negotiation of drug prices under Medi-Cal, the state’s Medicaid program; allow undocumented young people to stay on Medi-Cal up to age 26; expand eligibility for Affordable Care Act subsidies to individuals earning up to 600 percent of the poverty level; and reinstitute the ACA’s individual mandate.
  • In Washington state, Gov. Jay Inslee (D) and Democrats in the legislature announced a plan to begin work on a new “public option” for health insurance to be offered through the state’s health-care exchange.
  • Saying “From this moment on in New York City, everyone is guaranteed the right to health care,” New York City Mayor Bill De Blasio (D) announced a new initiative to offer coverage to all the city’s 600,000 uninsured, including undocumented immigrants, on a sliding scale based on income. 
  • In Maine, where troglodytic Republican former governor Paul LePage stymied efforts to accept the expansion of Medicaid despite the fact that voters approved it in an initiative, newly elected Gov. Janet Mills (D) used her first executive order to move ahead with the expansion. 
  • Democrats in Congress are moving forward to make the case for expanded health-care access despite their limited power. They will will be holding hearings on Medicare-for-all, and Rep. John Yarmuth (D-Ky.), the new chairman of the House Budget Committee, has requested analysis from the Congressional Budget Office on how a single-payer plan could be implemented. 

Meanwhile, the Hill reports: “Republicans are looking for a new message and platform to replace their longtime call to repeal and replace [the Affordable Care Act].” But I think we can confidently predict what their new message and platform will be: “This thing Democrats are suggesting will be disastrous!” It’s handy because you can apply it to any proposal, from the most modest market-oriented reform to the most ambitious reimagining of the entire system.


It would be naive not to acknowledge that the Republican message is often effective, particularly because it can be successfully mobilized to fight against change by telling people they’re going to lose something they now enjoy, or even just tolerate. Loss aversion — the tendency we all have to fear losing what we have to a greater degree than we value something we could gain — will be a powerful force against which Democrats will have to fight when they try to reform health care on the national level.

Republicans know this. That’s why their main argument against Medicare-for-all is to tell seniors that if it’s enacted, it means the end of Medicare. Don’t let everyone else benefit from the program you love! Or in President Trump’s typically subtle phrasing, “A vote for Democrats is also a vote to destroy Medicare.”

We don’t know how that debate is going to proceed over the next few years, or whether it will result in the United States finally joining every other industrialized country on Earth in having a system of universal health coverage guaranteed by the government. But there are some things we can say right now.


The first is that the debate has changed. Universal coverage generally, and single-payer specifically, which a short time ago were considered so radical they were barely worth discussing, are now part of any debate about our health-care future. Conservatives are horrified by that change, and still talk about universal coverage as though it was the equivalent of forcing all Americans to wait in line for bread wearing shapeless grey overcoats during a Moscow winter circa 1981. But conservatives have lost that first stage of the argument, in which we determine which policy options will be considered.

Second, universal coverage has become the default position of Democrats everywhere. There are certainly arguments about how to get there, but the argument within the Democratic Party is now about how to cover everyone, not whether to cover everyone. Every Democrat running for president in 2020 has either already embraced or will embrace universal coverage as a goal.

Third — and this is also new — as Democrats gain power, they will move aggressively to expand coverage, affordability, and security using any means available to them. It is similar to how when Republicans take power, they are immediately expected to cut taxes on businesses and the wealthy, and to restrict abortion rights. It’s probably what they want to do anyway, but if they had any hesitation, they know it’s what their constituents expect of them.

Much will depend on how successful some of these state-level experiments turn out to be. But the debate is now going to play out on terms that Democrats are setting.