Dems Quietly Start Their Next Big Health Care Effort

THERE ARE SIGNS that the debate about health care in America is about to get out of the rut it’s been in for about fifteen years—and that Democrats are preparing for the moment when it does.

Ever since 2010, the most high-profile fights in Washington have been about the Affordable Care Act and Medicaid. Mainly that’s because Donald Trump and the Republicans keep attacking those programs—as they did last year when they enacted the largest-ever cuts to Medicaid, then refused to extend lapsing “Obamacare” subsidies that had helped millions to get coverage, and reduced premiums for many millions more.

Democrats are determined to reverse those two steps, somehow, and you can expect them to make that a rallying cry in their campaigns for November’s midterm elections. But at least some Democrats don’t want to stop there. On March 19, a dozen of the party’s senators released an open letter announcing their intention to develop policies that would address a broader topic: The underlying increase in health care costs that is affecting everybody, not just people who are uninsured, on Medicaid, or buying coverage at HealthCare.gov.

The roughly 170 million Americans who get coverage through their employers are now paying (directly and indirectly) an estimated $27,000 a year on average for a family policy. “The American people need relief from rising premiums and deductibles that are forcing families into financial ruin,” the Senate Democrats wrote in their letter. “They also want an insurance system that doesn’t require them to jump through hoops and hack through red tape every time they need care.”

That may sound like a bunch of frothy boilerplate, given that the letter contained no specifics. But it’s not just these Democratic lawmakers who say it’s time to have a broader conversation, one that goes beyond undoing what Trump and the Republicans have just done. You hear the same thing from prominent analysts and advocates like Anthony Wright, president of the pro-coverage, pro-consumer organization FamiliesUSA.

“I do think people recognize that, as we wage the fight to defend coverage and consumer protection and specific communities under attack, that we don’t fall into a trap of defending the status quo that people thought rightly was broken,” Wright told me in an interview. “We need to show that we have a plan, not just to repeal bad stuff, or even to rebuild—but to reimagine what the health system should look like.”

That kind of reimagining can’t happen right away. Trump and the Republicans seem incapable of putting forward serious reform proposals, unless they involve hacking away at insurance coverage for people who need it. And the first chance Democrats might have to govern with a trifecta is nearly three years away. But it’s with an eye to that possibility that Democrats and their allies are starting to plan now—to make sure they are “prepared to take action on these issues the next time Democrats have an opportunity,” as the Senate Democrats put it in their letter.

And there’s an unmistakable parallel here, to a politically similar time when Democrats and their allies started laying the groundwork for future legislation. “This moment feels a bit like twenty years ago,” Larry Levitt, executive vice president for health policy at KFF, told me in an interview, “when groups of policy experts, advocates, and politicians started to talk about health care ideas that ultimately coalesced into the passage of the Affordable Care Act.”

But the challenge is different this time, and in some ways more difficult. Reducing health care costs inevitably involves reducing the flow of money into somebody’s pockets, which just as inevitably angers powerful constituencies and industry groups. Democrats aren’t even close to having a consensus on what to do. And 2029 is a lot closer than it might seem.

Share

ONE PERSON WHO KNOWS THIS all too well is Ron Wyden, the senator who organized the open letter and who hopes to lead discussions inside his caucus. He’s been focusing on health care ever since the 1970s, when as a freshly minted college graduate he helped to establish Oregon’s chapter of the Gray Panthers, a grassroots organization to defend the interests of seniors.

The unfailingly earnest Wyden will bring this up anytime you talk to him about health care. It’s part of his wonky charm, if you’ve gotten to know him as some of us have, and a point of information that is genuinely relevant. Helping elderly Americans get health care really has been a signature cause, going all the way back to 1981 when he first got to Congress.

In fact, when I spoke to Wyden last week, he said he was still angry over testimony that Mehmet Oz gave a year ago, during hearings for his confirmation as administrator of Medicare and Medicaid. The celebrity doctor had refused to stand by a Biden-era rule that raised the minimum staffing standards for nursing homes—requiring more personnel and a nurse on duty 24/7 by 2029—instead arguing that technology and telemedicine could take the place of extra staff.

“Are you kidding me,” Wyden said in our interview, “an 85-year-old woman trying to go to the bathroom in a dark bedroom is somehow going to be able to be safe and get there by an algorithm?”¹

But Wyden has also put in the time to think about and propose policies for non-elderly Americans. In late 2006, shortly after Democrats won control of the House and Senate in that year’s midterm election, he unveiled what he called the “Healthy Americans Act”—a detailed legislative proposal, complete with a financing scheme and independent analysis of its likely cost and impact.

It was a watershed moment, because it signaled that mainstream Democrats were serious about trying to enact legislation to achieve or at least approach universal coverage. Democratic leaders had mostly abandoned that effort in the 1990s, after a failed reform effort by then-President Bill Clinton helped to fuel a political backlash that ended up giving Republicans full control of Congress for the first time in decades.

Wyden’s proposal didn’t ultimately become the template for new reforms, partly because it envisioned everybody—even people who already had employer insurance—buying coverage on their own through newly regulated markets. That violated what most strategists believed was the single biggest lesson of the Clinton fiasco: Don’t mess with employer insurance, because it will spook anybody who has it already.

Another reason Wyden’s proposal didn’t go far was that he was not in charge