Any Chance For A Health Insurance Fix? Where The Debate Goes From Here

In the wake of Republicans failing to repeal and replace Obamacare and the Democratic takeover of the House, where will the health care debate go from here?

No important health care legislation will come out of this gridlocked Congress. But the run-up to the 2020 presidential campaign will produce at least a Democratic health care plan out of the nominating process.

Yes, House Democrats will hold a number of for-show votes on health care during the next two years—but they know none of them can go anywhere until they can win both the Senate and the White House.

The 2018 elections resulted in a number of Democrats calling for a Canadian-style single-payer plan. Two-thirds of incoming House Democratic freshman supported single-payer in the November elections—26 new members. That is in addition to the 123 House members in the last Congress supporting it, bringing the total to 149—a House majority is 218. Sixteen Democratic Senators also supported the Sanders single-payer plan in the last Congress.

But House Speaker Nancy Pelosi has made it clear she is not going to take Democrats in so controversial a direction—at least during the next two years. She remembers well the electoral damage the Obamacare program did to Democrats following its passage.

Instead she has said the House for now will focus on improving Obamacare.


Pelosi understands that enacting a government-run single-payer health insurance plans is a popular idea among her base. A November Gallup poll found 65% of Democrats favor some sort of government-run plan. But only 40% of overall voters support a government-run plan.

So, the Democratic leadership has to walk a tight rope–please the base who generally favors a government-run plan without alienating the general electorate that does not.

But Democrats can take heart from the same Gallup poll that found 57% of all voters believe that government should take a role in ensuring that people have health insurance coverage.

Pelosi seems to understand that single-payer health care has the potential for becoming political quicksand for Democrats.

In 2016, the left-leaning Urban Institute evaluated Bernie Sanders’ Medicare-For-All proposal, which would sweep all Americans into one government run-plan. They found that his plan would:

  • Increase national health expenditures by $6.6 trillion between 2016 and 2026.
  • Increase federal expenditures by $32 trillion between 2017 and 2026.
  • Fall way short of paying for itself—Sanders’ proposal would raise taxes by $15.3 trillion from 2017 to 2026 compared to the estimated federal price tag of $32 trillion during the same period—”thus the proposed taxes are much too low to fully finance his plan.”

In fact, Pelosi seems content to focus on improving Obamacare in this interim between taking back the House and the 2020 elections–where a more comprehensive proposal will emerge from the eventual Democratic nominee. That will likely lead Democrats to focus on two Obamacare-related proposals for now:

  1. Improving the insurance exchange subsidies for the middle class in the individual market who are struggling with astronomical unsubsidized premiums and deductibles. Forty percent of people in the individual market make too much money for any Obamacare subsidies.
  2. Making a point of protecting the preexisting condition reforms Republicans were able to bungle their way into looking like they wanted to undermine during their repeal and replace debate.

These two points of focus would be a political win/win for Democrats. They stay away from the political quicksand that health care overreach could produce while focusing on the middle class voters that Obamacare’s huge premiums have hurt, while protecting the universally popular medical underwriting reforms.

The Democratic controlled House may well pass legislation along these lines but it will go nowhere in the Republican controlled Senate. But that is not the House Democrat’s reason for focusing on improving Obamacare–they are doing it to keep the health care policy challenged Republicans off balance in the run-up to the 2020 elections.

I also don’t expect to see any of the other really serious Democratic presidential hopefuls embrace the Sanders single-payer plan. Instead I expect most will position themselves to look more moderate than Sanders. From most of the rest, I would look for more incremental proposals taken from a range of choices, which include:

  • Government directly negotiating drug prices.
  • Guaranteed insurability-for-all with Democrats coming out against the alternative individual market the Trump administration is now building around concepts like the short-term plans that don’t cover preexisting conditions.
  • Improved Obamacare subsidies—particularly for the middle class that have often been forced to drop their individual insurance out of affordability issues.
  • The return of the Medicare-like Public Option proposals for the Obamacare insurance exchanges.
  • Medicare buy-in for those age-50 and above.
  • Medicaid buy-in.
  • Medicare Advantage-For-All – Based upon similar proposals offered by the Center for American Progress and the Urban Institute that would generally sweep all but employer-based insurance into one giant federal program offering people the choice of Medicare, or what we now know as private Medicare Advantage plans.

That takes us to the Republicans.

In the wake of their whipping in the 2018 elections–much of that brought on by their ham-handed treatment of repeal and replace–what will be their 2020 health care plan?

I have no idea–and apparently at this point neither do they.

Just how Republicans will be able to coalesce around a cogent health care platform in the wake of their repeal and replace fiasco, with Trump in the lead, is hard for me to see.

I am not even sure where Republicans will begin and who could take the lead.