Universal health care in California: $17 billion a year, says one estimate

https://www.sfchronicle.com/business/article/The-price-tag-for-universal-health-care-in-13602501.php?utm_campaign=CMS+Sharing+Tools+%28Mobile%29&utm_source=m.facebook.com&utm_medium=referral&fbclid=IwAR1EEjMdhaai-HH9u6jq_Mo2aNNQ8cpAlmBD1J7Saxmb3c_rVag5HdVnrGc

Universal health care in California could cost $17.3 billion a year, under one plan proposed Friday by UC Berkeley health policy researchers.

The paper offers one path for getting about 3 million uninsured Californians health coverage. It is one of several recent estimates from researchers and legislators who have devised various ways to work toward universal coverage in the state. It is not a plan for a single-payer system.

The figure is significantly higher than other analyses, which found that working toward universal coverage by expanding Medi-Cal insurance for the poor would cost less than half of that. That is because the paper builds in the assumption that the uninsured would get on private health insurance plans, whereas other estimates factor in federal funding for getting more people on Medi-Cal, which is jointly paid for by the federal and state governments.

The paper, by Richard Scheffler and Stephen Shortell of Berkeley’s School of Public Health, proposes a mix of new taxes on the health care industry, California employers and airline travelers, paired with contributions from the state’s general fund and premium payments from individuals who are now uninsured.

The ideas, presented Friday to a group of California health policy researchers and advocates, are considered one early stab at financing universal coverage and are not included in legislative proposals.

The largest source of financing, 41 percent, would come from a 3 percent tax on the revenue of hospitals, nursing homes, drug companies, home care providers and insurance companies, which would generate an estimated $7.2 billion a year. The tax would not apply to public hospitals.

The next largest source of funding, 31 percent or $5.2 billion, would come from currently uninsured residents who would pay a monthly premium for a health plan — envisioned as a plan bought through the insurance marketplace Covered California. The premium would be paid by those who earn too much to qualify for Medi-Cal, the insurance program for the poor, and would average out to $123 a month per person. The authors do not specify how many people would pay this premium, or address how to incentivize this population — many of whom are undocumented and hesitant to participate in government programs — to buy into the system.

The paper also proposes a tax on international and business class travelers who fly into and out of California’s five largest airports: Los Angeles International Airport, San Francisco International Airport, San Diego International Airport, Oakland International Airport and San Jose International Airport. The taxes would be $50 per ticket for domestic business class passengers, $60 per ticket for for economy international passengers and $250 per ticket for international business passengers. These five airports see a collective 188 million passengers each year, according to the authors’ analysis of California Department of Transportation air passenger traffic data. The tax would generate $2.3 billion a year.

The remaining funding would come from the state’s general fund in the amount of $1.7 billion, and a tax on employers that would generate $979 million. The employer tax would be modeled after Healthy San Francisco, a program started in 2007 to cover the city’s 14,000 uninsured residents. It would require employers that don’t provide insurance to their workers to pay into a fund by levying a 4 percent surcharge on customers. It would apply to for-profit employers with more than 20 workers and nonprofit employers with more than 50 workers.

Under the plan, the revenue generated through these proposed new taxes would go toward what’s known as integrated care systems to expand their geographic reach and offer more insurance plans on Covered California. The biggest and most well-known integrated system is Kaiser, which provides both the insurance coverage and health care services to its patients, but others have started forming their own integrated care systems in recent years including Sutter Health’s HMO plan, Sharp Health Care in San Diego and HealthCare Partners in Los Angeles. Those integrated care plans would be offered on Covered California.

Scheffler and Shortell say they hope their ideas are a starting point for debate and will inspire action by state legislators.

“We’re hoping for some interest from Sacramento,” Scheffler said.

Some policy experts who reviewed the paper raised questions about some of the proposed taxes and the cost estimate. Ken Jacobs, chair of the UC Berkeley Labor Center, said $17 billion is much too high for achieving universal coverage because it doesn’t take into account the federal dollars that would be available if the state were to expand Medi-Cal to more uninsured people.

A state-level employer mandate could face legal challenges, as Healthy San Francisco did, because of federal preemption issues under the Employee Retirement Income Security Act, or ERISA, Jacobs said. Similarly, the airline tax might run afoul of federal laws regulating interstate commerce and airlines. And the tax on hospitals would need a two-thirds vote in the Legislature and buy-in from health care providers.

“I look at the (financing) as throwing some ideas on the table to start a discussion,” Jacobs said.

Other proposed measures and analyses put different cost estimates for getting California closer to universal coverage. A report released this month by Covered California found that providing more financial assistance to consumers to buy plans would cost between $2.1 billion and $2.7 billion a year.

One bill, AB-4, proposes expanding Medi-Cal to all undocumented adults — a move the Legislative Analyst’s Office has estimated would cost $3 billion annually. Another bill, AB-174, aims to provide financial assistance to those making between $48,000 and $72,000 to buy insurance. It would cost $40 million to $75 million a year, according to estimates included in a previous bill.

Gov. Gavin Newsom’s proposed budget included expanding Medi-Cal coverage to undocumented young adults between ages 19 and 25, and providing state-funded financial assistance to help Californians buy insurance — both of which would be steps toward universal coverage in the state. It is unclear how much the initiatives would cost.

 

Democrats Have No Safe Options On Health Care

Democrats Have No Safe Options On Health Care

Even though most of the candidates have committed to some form of universal health care, the Democratic primary is turning into a debate about the future of the country’s health care system. Presidential hopefuls have proposed policies ranging from an ambitious four-year plan to transform Medicare into a universal single-payer system, in which the government pays for everyone’s health care and private insurance plans are effectively eliminated, to a more modest scheme that would leave the existing health care system intact but create a government-administered public insurance plan people could choose to purchase. But some of the candidates have been light on policy specifics, so it’s likely that health care will be a big topic at the debates and beyond.

In the abstract, focusing on health care makes a lot of political sense for Democrats. It was a top issue among Democratic voters in the 2018 midterms, and the Trump administration recently renewed its efforts to strike down the Affordable Care Act in the courts, which means the law could be hanging in the balance throughout the primaries and into the general election. A recent ABC News/Washington Post poll also found that Americans, by a 17-point margin, say that President Trump’s handling of health care makes them more likely to oppose him than to support him in 2020. By a similar margin, an Associated Press/NORC poll found that Americans trust Democrats more than Republicans on health care.

All of this means that Democrats are heading into the 2020 election cycle with a serious edge on an issue that has the potential to mobilize their base. But if the candidates pitch big, sweeping changes to the health care system without addressing voters’ concerns about cost and access, that advantage won’t necessarily hold up. And trying to sell Americans on a completely new system carries risks, even in the primaries.

Why do people care about health care so much?

First, it’s important to understand how health care has morphed over the past decade from just another issue to one of the issues voters care most about. In the 2018 exit polls, 41 percent of voters said health care was the most important issue facing the country, up from 25 percent in 2014 and 18 percent in 2012. (It wasn’t asked about in 2016.) And although Democrats are more likely to prioritize health care than Republicans, a Pew Research Center poll from January found that a majority of Republicans say health care costs should be a top priority for Congress and the president.

The reason? Health care is becoming more of a financial burden, according to Mollyann Brodie, executive director for public opinion and survey research at the Kaiser Family Foundation. Specifically, Americans’ out-of-pocket health care costs have risen significantly over the past decade, even for workers who get insurance through their jobs. In an economy that by many measures is doing well, health care — rather than something like taxes — is becoming one of voters’ most important pocketbook issues, she said. “If you’re worried about whether you or your loved ones can afford your next health care bill, that’s really a matter of life or death, so you can understand why this issue is moving to center stage politically.”

And Americans are increasingly likely to say that the government has an important role to play in ensuring access to health care. In November, Gallup found that 57 percent of Americans said they think it’s the federal government’s responsibility to ensure that everyone has health care coverage, up from a low of 42 percent in 2013. Support for the Affordable Care Act rose over the same period, too. But, notably, support for government intervention in the health care system was even higher before President Obama was elected and the ACA passed — in 2006, 69 percent of Americans thought the government should guarantee health care coverage.

While support for government involvement in health care is rebounding, it’s not clear how much change voters are really asking for. “The average American is first and foremost concerned about the financial problems facing their family,” said Robert Blendon, a professor of health policy and political analysis at Harvard. “They’re less worried about system-level concerns like health care spending and inequality. They want their existing coverage to be better and more affordable.”

What do voters want politicians to do?

Americans aren’t opposed to the idea of government-run health care, but there’s not a lot of consensus on what that would mean. For example, a recent Kaiser Family Foundation poll found that a majority (56 percent) of Americans favor a national “Medicare for All” plan. But according to a March Morning Consult poll, Americans are more likely to favor a plan that offers some kind of public option — a government-sponsored health insurance plan available in addition to existing private plans — over a system where everyone is enrolled in the same plan.

But this apparent contradiction makes sense, according to Brodie, because Americans are risk-averse when it comes to health care, and the switch to single-payer would affect far more people than the ACA did. Tens of millions of previously uninsured people received coverage under the ACA, but that number would be dwarfed by the 156 million people who get their insurance through their employers and could see their coverage change if the country switched to a single-payer plan. “Even if the current system isn’t working, transitions are scary,” Brodie said. “And people aren’t necessarily aware of what a national plan really means. When you start telling people that there might not be any more private insurance companies, that’s actually not a popular position.” For example, a January Kaiser Family Foundation poll found that support for a national Medicare for All plan dropped significantly when respondents were told it would mean eliminating private insurance companies.

And when asked what health care policies they want Congress to prioritize, Americans don’t list Medicare for All first. Instead, according to a recent Kaiser Family Foundation poll, they want Congress to pass targeted measures that would lower prescription drug costs, continue the ACA’s protections for preexisting conditions and protect people from surprise medical bills. Only 31 percent of Americans say that implementing Medicare for All should be a top priority for Congress, compared to 68 percent who want lowering drug prices to be a top priority. Moreover, prioritizing Medicare for All is politically polarizing: Only 14 percent of Republicans support putting that kind of plan at the top of the to-do list, compared to 47 percent of Democrats.

Some health care issues get only one-sided support

Share of Republicans and Democrats who say each issue should be a top priority for Congress, and the difference between the parties

Dem. Rep. Diff.
Making sure the ACA’s preexisting condition protections continue 82% 47% D+35
Implementing a national Medicare for All plan 47 14 D+33
Expanding government financial help for those who buy their own insurance coverage on the ACA marketplace to include more people 36 18 D+18
Lowering prescription drug costs for as many Americans as possible 77 66 D+11
Protecting people from surprise high out-of-network medical bills 55 45 D+10
Repealing and replacing the ACA 16 52 R+36

Source: Kaiser Family Foundation

However, smaller policy steps like lowering prescription drug costs and protecting people from surprise medical bills get more bipartisan support. Overall, Americans seem to be more concerned with fixing the current health care system than creating a sweeping new replacement — even if that replacement could address the issues they most want fixed in the current system.

What does this mean for the Democrats?

The complexity of Americans’ views on health care doesn’t change the fact that Democrats have a big advantage over Republicans on this issue, but it does mean that the individual candidates are in a tough spot because there’s no obvious unifying message they can adopt for the primary. And embracing a single-payer plan now could hand the GOP a weapon for the general election, allowing Republicans to frame the health care discussion around the Democrats’ controversial plan while glossing over Trump’s efforts to dismantle the ACA.

“The safest bet for a Democrat in the general election is to emphasize Trump’s track record on health care and say you’re going to make the ACA work,” Blendon said. The problem is that while that kind of argument might appeal to moderates, it’s likely to fall flat among a significant sector of the Democratic base that supports prioritizing a national Medicare for All plan over improving and protecting the ACA.

Democrats arguably still have an opening to make a case for a more ambitious health care overhaul, since voters still have relatively little information about what something like Medicare for All means. “It’s fine to support single-payer if you think that’s where the country needs to go, but you can’t just lean on principles like fairness or equality when you’re selling it,” said David Cutler, an economist at Harvard who advised Obama’s campaign on health care strategy. “You also have to tell voters, very specifically, what you are going to do to lower their costs and improve their coverage next year — not in 10 years.”

Even though Americans mostly prefer Democrats’ health care positions to the GOP’s, Democrats still risk alienating voters if they emphasize bumper-sticker slogans over concrete strategies for reducing the financial burden of health care. This is particularly important because their base of support for a single-payer system may be shallower than it appears, even within the party — especially when it comes to getting rid of private insurance. Big changes to the status quo are always politically challenging, but they may be especially risky when many Americans are concerned about losing the protections they already have.

 

 

 

Considering “Single Payer” Proposals in the U.S.: Lessons from Abroad

https://www.commonwealthfund.org/publications/2019/apr/considering-single-payer-proposals-lessons-from-abroad

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ABSTRACT

  • Issue: When discussing universal health insurance coverage in the United States, policymakers often draw a contrast between the U.S. and high-income nations that have achieved universal coverage. Some will refer to these countries having “single payer” systems, often implying they are all alike. Yet such a label can be misleading, as considerable differences exist among universal health care systems.
  • Goal: To compare universal coverage systems across three areas: distribution of responsibilities and resources between levels of government; breadth of benefits covered and extent of cost-sharing in public insurance; and role of private insurance.
  • Methods: Data from the Organisation for Economic Co-operation and Development, the Commonwealth Fund, and other sources are used to compare 12 high-income countries.
  • Key Findings and Conclusion: Countries differ in the extent to which financial and regulatory control over the system rests with the national government or is devolved to regional or local government. They also differ in scope of benefits and degree of cost-sharing required at the point of service. Finally, while virtually all systems incorporate private insurance, its importance varies considerably from country to country. A more nuanced understanding of the variations in other countries’ systems could provide U.S. policymakers with more options for moving forward.

Background

Despite the gains in health insurance coverage made under the Affordable Care Act, the United States remains the only high-income nation without universal health coverage. Coverage is universal, according to the World Health Organization, when “all people have access to needed health services (including prevention, promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship.”1

Several recent legislative attempts have sought to establish a universal health care system in the U.S. At the federal level, the most prominent of these is Senator Bernie Sanders’ (I–Vt.) Medicare for All proposal (S. 1804, 115th Congress, 2017), which would establish a federal single-payer health insurance program. Along similar lines, various proposals, such as the Medicare-X Choice Act from Senators Michael Bennet (D–Colo.) and Tim Kaine (D–Va.), have called for the expansion of existing public programs as a step toward a universal, public insurance program (S. 1970, 115th Congress, 2017).

At the state level, legislators in many states, including Michigan (House Bill 6285),2 Minnesota (Minnesota Health Plan),3 and New York (Bill A04738A)4 have also advanced legislation to move toward a single-payer health care system. Medicare for All, which enjoys majority support in 42 states, is viewed by many as a litmus test for Democratic presidential hopefuls.5 In recent polling, a majority of Americans supported a Medicare for All plan.6

Medicare for All and similar single-payer plans generally share many common features. They envision a system in which the federal government would raise and allocate most of the funding for health care; the scope of benefits would be quite broad; the role of private insurance would be limited and highly regulated; and cost-sharing would be minimal. Proponents of single-payer health reform often point to the lower costs and broader coverage enjoyed by those covered under universal health care systems around the world as evidence that such systems work.

Other countries’ health insurance systems do share the same broad goals as those of single-payer advocates: to achieve universal coverage while improving the quality of care, improving health equity, and lowering overall health system costs. However, there is considerable variation among universal coverage systems around the world, and most differ in important respects from the systems envisioned by U.S. lawmakers who have introduced federal and state single-payer bills. American advocates for single-payer insurance may benefit from considering the wide range of designs other nations use to achieve universal coverage.

This issue brief uses data from the Organisation for Economic Co-operation and Development (OECD), the Commonwealth Fund, and other sources to compare key features of universal health care systems in 12 high-income countries: Australia, Canada, Denmark, England, France, Germany, the Netherlands, Norway, Singapore, Sweden, Switzerland, and Taiwan.

We focus on three major areas of variation between these countries that are relevant to U.S. policymakers: the distribution of responsibilities and resources between various levels of government; the breadth of benefits covered and the degree of cost-sharing under public insurance; and the role of private health insurance. There are many other areas of variation among the health care systems of other high-income countries with universal coverage — such as in hospital ownership, new technology adoption, system financing, and global budgeting — that are beyond the scope of this discussion.

 

 

 

 

 

 

Can the State of California Afford to Provide Universal Health Care Coverage?

http://www.foxandhoundsdaily.com/2019/01/can-the-state-of-california-afford-to-provide-universal-health-care-coverage/

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Perhaps no issue looms larger on both the state and national political stage than the question of universal health care coverage.

U.S. Presidential hopeful Kamala Harris (D) sent a shockwave through the national health care debate on Monday Jan. 28th by nonchalantly stating that she would eliminate private insurers as a necessary part of implementing “Medicare-for-all,” according to a CNN report.

Due to a firestorm of attention, most of it negative, the next day the Harris campaign walked back the previous day’s remarks in large part by stating that the candidate would also be open to more moderate health reform plans, which would preserve the private industry, according to the CNN report.

Newly elected California Governor Gavin Newsom (D) campaigned on the issue of single-payer health care and on his very first day in office unveiled a comprehensive package of reform proposals aimed at expanding state health care coverage subsidies and lowering its costs, which includes extending Medi-Cal to undocumented immigrants, according to a report by the LA Times.

In an interview, Gov. Newsom told the LA Times “These are not just symbolic gestures…We’re hoping to ignite a new conversation. It’s a moral imperative, not just economic,” states the LA Time report.

But as many experts, including Gov. Newsom, have pointed out, big systemic reform to the system, such as a move to a single-payer health system, would require the unlikely support of the Trump Administration.

Newsom has done a good job of tempering expectations for single-payer health care and his proposed coverage expansions and prescription cost controls demonstrate to the his supporters and the public that he is serious about expanding coverage as well containing costs.

But the 800-pound guerilla in the universal health care conversation is where will all the money come from to provide guaranteed government financed coverage to every Californian and everyone who likely to come to California once universal health care is guaranteed by the state?

“Where do you get the extra money? This is the whole question…I don’t even get it…how do you do that?,” said former California Governor Jerry Brown (D) following a universal healthcare discussion in Washington, D.C. in a 2017 interview with the LA Times.

At the time, Gov. Brown pointed out that the overall cost of medical care in California is equal to 18% of the state’s gross domestic product, which would be about $450 billion.

“You take a problem and say I’m going to solve it by something that’s an even bigger problem, which makes no sense,” then Governor Brown said at the time, according to the LA Times report.

Gov. Newsom developed some questionable rhetoric during the 2018 campaign, where he said that the State of California cannot afford not to move to a single-payer system because health care has become such a big expense in the state.

It appears that one of the major points of disagreement between former Gov. Brown and now Governor Gavin Newsom is the question of whether the State of California can afford to move to a universal health care system, specifically a single-payer system?

More recently, other high-profile liberal Democrats have come out against single-payer health care with former Mayor of New York City and billionaire Michael Bloomberg stating that Medicare-for-all “would bankrupt us for a very long time,” according to a CNN report.

“I think we could never afford that,” Bloomberg said, addressing pin factory employees in New Hampshire. “We are talking about trillions of dollars.”

“I think you could have Medicare-for-all people who are uncovered, but that’s a smaller group,” Bloomberg said.

“But to replace the entire private system where companies provide health care for their employees would bankrupt us for a very long time,” said Bloomberg according to the CNN report, which noted that Bloomberg made the comments in response to Sen. Kamala Harris calling for an end to the private health care market.

So what does all this mean for the current universal health care debate in California?

It means that California Democrats might want to heed the advice of two of the county’s most prominent liberal Democrats—former Gov. Jerry Brown and Michael Bloomberg—and proceed with great caution regarding the feasibility of California going it alone on universal health care.

There is no question that the state could choose to enact a single-payer or Obamacare-type universal health care system, but the million dollar question, or trillion dollar question rather in this case, is would such a system work and be fiscally sustainable over the long-term?

As a long-time analyst of fiscal issues in California, I believe that former Gov. Jerry Brown and Michael Bloomberg are correct to point out the major challenges and risks of moving to a universal health care system—both at the state level and the federal level.

 

 

Health Care Is on Agenda for New Congress

https://www.scripps.org/blogs/front-line-leader/posts/6546-ceo-blog-health-care-is-on-agenda-for-new-congress

After months of polls, mailbox fliers, debates and seemingly endless commercials, the mid-term elections are over and the results are in. As predicted by many, the Democrats have won back the majority in the U.S. House of Representatives, while the Republicans have expanded their majority in the Senate.

This means that for the first time since 2015 we have a divided Congress, which leaves me pondering the possible consequences for Scripps Health and the broader health care sector.

Without a doubt, health care will be on the agenda for both parties over the coming months. That became apparent during pre-election campaigning as voters on both sides of the political spectrum voiced concerns about a wide range of health care-related issues.

Exit polls found that about 41 percent of voters listed health care as the top issue facing the country, easily outpacing other issues such as immigration and the economy.

That’s really no surprise. Health care affects all of us, whether we’re young or old, poor or well off, or identify as more conservative or more liberal. And despite all of the division around the country, most Americans seem to agree on at least a few things – health care costs too much, more needs to be done to rein in those costs, everyone should have access to health insurance, and pre-existing condition shouldn’t be a disqualifier for getting coverage.

When the new Congress convenes on Jan. 3, a wide range of health care issues will be on the agenda.

Here are a few of the issues that I’ll be watching as our lawmakers adjust to the reshuffled political dynamics in Washington.

  • Repealing elements of the Affordable Care Act (ACA) is likely off the table now that Democrats control the House. Previously, House Republicans had voted to change a number of ACA provisions that required health insurance policies to cover prescription drugs, mental health care and other “essential” health benefits. But even before the election, Republicans had reassessed making changes to measures that protect people with pre-existing conditions as that issue gained traction with voters.
  • Efforts to expand insurance coverage and achieve universal health care will likely increase. A number of newly elected Democrats vowed to push for a vote on the single-payer option, but other less politically polarizing options such as lowering the eligibility age for Medicare and expanding Medicaid likely will draw more support.
  • While Republicans used their majority in the House to reduce the burden of government regulations in health care and other industries, Democrats might use their new-found power to initiate investigations on a wide range of matters such as prescription drug costs.

We could see some significant changes take place at a more local level as well. On Tuesday, voters in three states approved the expansion of Medicaid, the government program that provides health care coverage for the poor.

And here in California, we will be watching newly elected Governor Gavin Newsom to see what plans he will put forward for expanding health care coverage in this state.

At Scripps, we believe everyone should have access to the health care services that they need, and we have worked hard in recent years to do all that we can to bring down the costs of delivering that care to our patients.

In this new world of divided government, gridlock likely will prevail and President Trump’s initiatives will struggle in the Democrat-controlled House. Everyone will be focused on positioning themselves and their party for the next presidential and congressional elections in two years.

Compromise and bipartisanship are clearly the best options for addressing the health care challenges we now face in ways that have the best chance to win wide public support.

If Democrats in the House fail to reach across the aisle to Republicans or try to make too many changes too quickly, they surely will face many of the same pitfalls that confronted Republicans over the last two years.

 

 

Forty Years of Winning Friends and Influencing People

https://www.chcf.org/blog/forty-years-of-winning-friends-and-influencing-people/

An interview with former US Representative Henry Waxman of California.

Of the more than 12,000 Americans who have served in Congress since it convened in 1789, few have had careers as fruitful as Henry Waxman’s. Representing west Los Angeles and its surrounding areas for 40 years, Waxman, 78, left a remarkable imprint on US health policy. His manifold accomplishments were capped by the passage of the Affordable Care Act (ACA) in 2010. A son of south-central Los Angeles, he worked at his father’s grocery store, earned a law degree at the University of California, Los Angeles, and in 1968 won a seat in the State Assembly. He was elected to the US House in 1974 in an era when bipartisanship was ordinary and health care had yet to become an overwhelming economic and political force in American life. Waxman was known in Congress for his persistence at wearing down opposition. Republican Senator Alan Simpson of Wyoming famously called him “tougher than a boiled owl” after negotiating the landmark Clean Air Act amendments of 1990. Waxman led efforts to ban smoking in public places and to require nutrition labels on food products. I talked with him recently about his experiences, the future of health policy, and the changing language of health reform. The transcript has been lightly edited for length and clarity.

Q: In 1974, when Los Angeles voters first sent you to Washington, health policy wasn’t the ticket to political influence. You are a lawyer, not a doctor. What drew you to health care?

A: When I was first elected to the California State Assembly in 1968, I believed that if I specialized in a policy area I would have more impact than if I tried to be an expert on everything. Health policy fit my district in Los Angeles, and I could see that government needed to be involved in a whole range of decisions, from health care services to biomedical research to public health. I was chairman of the Assembly Committee on Health. I was elected to Congress in 1974 in a Democratic wave election. I wanted to get on a health policy committee, which was Energy and Commerce. Democrats picked up so many seats and there were so many committee vacancies that year that it was easy to claim one, and I got on that committee. Within four years there was a vacancy for chair of the health and environment subcommittee, and I stepped up to that. It gave me a lot more impact.

Q: What role do you think health care will play in the upcoming elections?

A: If the Democrats do as well as I expect and hope, it will be more because of what Trump was doing in the health area than anything else. Even though people value health care services and insurance, the idea that the president and the GOP wanted to take away health insurance and reduce benefits for people who needed it — that was something they didn’t expect and were angry about.

Q: Is it feasible to provide health coverage to everyone?

A: I have always felt we needed access to universal health coverage. It wasn’t until we got the ACA under Obama that we were able to narrow the gap of the uninsured — those who couldn’t get insurance through their jobs, who weren’t eligible for Medicare and Medicaid, who had preexisting conditions, or who couldn’t afford the premiums. The ACA helped people have access to an individual health policy by eliminating insurance company discrimination and giving a subsidy to those who couldn’t afford coverage. It wasn’t a perfect bill, but it was important. The idea that Republicans would come along and bring back preexisting conditions as a reason to deny people coverage is what drove enough GOP senators to stop the GOP repeal bill from going forward last year. We’ll see what they do by way of executive orders or through the courts to try to frustrate people’s ability to buy insurance.

The Republican ACA repeal bill last year was a real shock because they also wanted to repeal the Medicaid program and allow states to cut funds for people in nursing homes, people with disabilities, and low-income patients who rely so heavily on that program. And they had proposals to hurt Medicare that House Speaker Paul Ryan had been advancing. The American people do not want to deny others insurance coverage and access to health services.

Q: Bipartisanship has gone out of style. Can it be revived?

A: It doesn’t look very likely now, but I built my legislative career on the idea that there could be bipartisan consensus to move forward on legislation. All the big bills had bipartisan support. The only bill that got through on a strictly partisan basis was the Obamacare legislation, and I regretted that. The Republicans just wanted to denigrate it and scare people into believing the ACA would provide for death panels, hurt people, take away their insurance, and keep them from getting access to care. None of that was true.

Q: A growing number of Democrats want to establish a single-payer health care system for the state. Do you agree with them?

A: A lot of people mistake the phrase “single payer” with universal health coverage. While I share the passion of people who want to cover everybody, single payer is not a panacea. My goal is universal health coverage. The Republican attempt last year to repeal the ACA and send 32 million Americans into the ranks of the uninsured was an albatross around their necks.

But the Democrats could turn this winning issue into a loser if some make a single-payer bill such as Medicare for All into a litmus test. I cosponsored single-payer legislation in Congress with Senator Ted Kennedy, and I always sought to bring the nation closer to universal coverage. I authored laws to bring Medicaid to more children and to establish the Children’s Health Insurance Program, and I led the fight to enact the ACA. These bills were very important. If we passed something like a single-payer bill, which would be extremely hard to do, we would be passing up opportunities to make progress. A lot of people who want a Medicare for All bill don’t realize that those of us on Medicare have to pay for supplemental insurance, because Medicare doesn’t cover everything. Medicare doesn’t generally cover certain services like nursing home care, so to get help you have to impoverish yourself to qualify for Medicaid.

One organization is sending out letters telling voters to support a single-payer bill and you won’t have to pay anything anymore. We can’t afford something like that. Democrats can embrace a boundless vision for a health care future without being trapped by a rigid model of how to get there. We should increase the number of people with comprehensive health insurance and focus on lowering costs. People with Medicare don’t want to give it up. People have health insurance on the job.

I would rather expand on what we have and build it out to cover everybody.

People don’t seem to remember that Democrats could barely muster the votes for the ACA when we had 60 votes in the Senate and a 255–179 majority in the House. Even if we recapture Congress and the presidency, I don’t think we would get a Medicare for All bill passed. It would require such a high tax increase that people would be absolutely shocked.

Q: What would be the national impact of California adopting a universal coverage plan?

A: Californian progress would be a model for the rest of the country, and we would be doing what’s right for the people of California who don’t have access to coverage. I think California is a trendsetter — for good and for bad. Proposition 13 and term limits started in California and spread to other states, and I think they have been a disservice. We’ve also done a lot of good things in California, and the rest of the country follows those things as well.

People who try to marginalize California do so at their own risk. People around the country look at California as a leader. California embraced the ACA, expanded Medicaid, and has been moving forward on making sure our public health care system is reforming itself to represent the needs for population health care and to ensure that uninsured low-income patients get access to decent, good-quality health care.

Q: More states are adopting work requirements in Medicaid. Do you think that will become the standard nationwide?

A: Work requirements are inconsistent with the Medicaid law. We’re talking about making people go to work to get health care when they’re sick. I just don’t think it makes sense. The courts may throw it out, and if not, at some point there will be a reaction against it, and it will be repealed by a future Congress.

Q: Some see parallels between the conduct of tobacco companies and opioid makers. Do you think “Big Pharma” will be held to account like “Big Tobacco?”

A: In the difficult fight against big tobacco, one of the lessons we learned was that even an extremely powerful group like the tobacco industry could be beaten if you keep pushing back. Even though there was overwhelming public support for regulation of tobacco, it took until 2009 before we could enact tobacco regulation by giving the Food and Drug Administration (FDA) authority to act. In the meantime, there were lawsuits by states to recover money they spent under Medicaid programs to cope with the harm from smoking. With opioids, there will be more and more lawsuits against distributors and manufacturers whose actions resulted in deaths of people from opioid addiction. Congress now is grappling with many bills to help people who are addicted, to prevent addiction from spreading further, and to restrict the ability to get the drug product. I’m optimistic we can come to terms with this crisis.

Q: What have you been doing since retiring from Congress?

A: I wanted to stay in the DC area near my son, Michael Waxman, and his family. He had a traditional public relations firm and he asked me to join him. In the health area, we represent Planned Parenthood in California, public hospitals in California, community health centers at the national level, and hospitals that get 340b drug discounts because they serve many low-income patients. We have foundation grants to work on problems of high pharmaceutical prices, and foundation grants to have a program to make sure women know about the whole range of health services available to them for free under the ACA. I enjoy working with my son and pursuing causes I would have pursued as a member of Congress.

 

 

 

Getting Ready for Health Reform 2020: What Past Presidential Campaigns Can Teach Us

https://www.commonwealthfund.org/publications/fund-reports/2018/jun/getting-ready-health-reform-2020-presidential?omnicid=EALERT%%jobid%%&mid=%%emailaddr%%

Getting Ready for Health Reform 2020

Abstract

  • Issue: The candidates for the 2020 presidential election are likely to emerge within a year, along with their campaign plans. Such plans will include, if not feature, health policy proposals, given this issue’s general significance as well as the ongoing debate over the Affordable Care Act.
  • Goal: To explain why campaign plans matter, review the health policy components of past presidential campaign platforms, and discuss the likely 2020 campaign health reform plans.
  • Methods: Review of relevant reports, data, party platforms, and policy documents.
  • Findings and Conclusions: Proposals related to health care have grown in scope in both parties’ presidential platforms over the past century and affect both agendas and assessments of a president’s success. Continued controversy over the Affordable Care Act, potential reversals in gains in coverage and affordability, and voters’ concern suggest a central role for health policy in the 2020 election. Republicans will most likely continue to advance devolution, deregulation, and capped federal financing, while Democrats will likely overlay their support of the Affordable Care Act with some type of Medicare-based public plan option. The plans’ contours and specifics will be developed in the months ahead.

This report is the first in a series on health reform in the 2020 election campaign. Future papers will delve into key reform design questions that candidates will face, focusing on such topics as: ways to maximize health care affordability and value; how to structure health plan choices for individuals in ways that improve system outcomes; and how the experience of other nations’ health systems can inform state block-grant and public-plan proposals.

Introduction

During the 2020 presidential campaign, which begins in earnest at the end of 2018, we are sure to hear competing visions for the U.S. health system. Since 1988, health care has been among the most important issues in presidential elections.1 This is due, in part, to the size of the health system. In 2018, federal health spending comprises a larger share of the economy (5.3%) than Social Security payments (4.9%) or the defense budget (3.1%).2 Moreover, for the past decade, partisan disagreement over the Affordable Care Act (ACA) has dominated the health policy debate. If health care plays a significant role in the 2018 midterm elections, as some early polls suggest it will,3 the topic is more likely to play a central role in the 2020 election.

This report on health reform plans focuses on policies related to health insurance coverage, private insurance regulation, Medicare and Medicaid, supply, and tax policy. It explains why campaign plans are relevant, their history since 1940, the landscape for the 2020 election, and probable Republican and Democratic reform plans. The Republican campaign platform is likely to feature policies like those in the Graham-Cassidy-Heller-Johnson amendment: a state block grant with few insurance rules, replacing the ACA’s coverage expansion. The Democratic platform will probably defend, improve, and supplement the ACA with some type of public (Medicare-like) health plan. The exact contours and details of these plans have yet to be set.

Importance of Campaign Plans

Campaign promises, contrary to conventional wisdom, matter.4 During elections, they tell voters each party’s direction on major topics (e.g., health coverage as a choice or a right in 1992). In some cases, candidates or party platforms include detailed policies (reinsurance in Republicans’ 1956 platform, prospective payment in Democrats’ 1976 platform). Campaign plans tend to be used to solidify party unity, especially in the wake of divisive primaries (2016, e.g.).5 Election outcomes are affected by such factors as the state of the economy, incumbency, and political competition rather than specific issues.6 That said, some exit polls suggest that candidates’ views on health policy can affect election outcomes.7

Campaign plans also help set the agenda for a president, especially in the year after an election. Lyndon B. Johnson told his health advisers, “Every day while I’m in office, I’m gonna lose votes. . . . We need . . . [Medicare] fast.”8 Legislation supported by his administration was introduced before his inauguration and signed into law 191 days after it (Exhibit 1). Bill Clinton, having learned from his failure to advance health reform in his first term, signed the bill that created the Children’s Health Insurance Program (CHIP) 197 days after his second inauguration. Barack Obama sought to sign health reform into law in the first year of his first term, but the effort spilled into his second year; he signed the ACA into law on his 427th day in office. These presidents, along with Harry Truman, initiated their attempts at health reform shortly after taking office.

In addition, campaign plans are used by supporters and the press to hold presidents accountable. For instance, candidate Obama’s promises were the yardstick against which his first 100 days,9 first year,10 reelection prospects,11 and presidency were measured.12 Though only 4 percent of likely voters believe that most politicians keep their promises, analyses suggest that roughly two-thirds of campaign promises were kept by presidents from 1968 through the Obama years.13

Health as a Campaign Issue (1912–2016)

The United States has had public health policies since the country’s founding, with its policy on health coverage, quality, and affordability emerging in the twentieth century. Teddy Roosevelt supported national health insurance as part of his 1912 Bull Moose Party presidential bid.14 Franklin Delano Roosevelt included “the right to adequate medical care and the opportunity to achieve and enjoy good health” in his 1944 State of the Union address, although it was not mentioned in the 1944 Democratic platform.15 Harry Truman is generally credited with being the first president to embrace comprehensive reform. He proposed national health insurance in 1945, seven months after F.D.R.’s death, and campaigned on it in 1948 as part of a program that would become known as the Fair Deal, even though it was not a plank in the Democratic platform. Legislation was blocked, however, primarily by the American Medical Association (AMA), which claimed that government sponsoring or supporting expanded health coverage would create “socialized medicine.”16 Health policy became a regular part of presidential candidates’ party platforms beginning about this time (Exhibit 2).

After Truman’s failure, the next set of presidential candidates supported expanding capacity (e.g., workforce training, construction of hospitals and clinics) and making targeted coverage improvements. In 1960, John F. Kennedy campaigned on a version of Medicare legislation: extending Social Security to include hospital coverage for seniors. It was opposed by the AMA as well, whose spokesman, the actor Ronald Reagan, claimed socialized medicine would eventually limit freedom and democracy.17 It took the death of Kennedy, the landslide Democratic victory in 1964, and persistence by Lyndon B. Johnson to enact Medicare and Medicaid, in 1965. This was about 20 years after Truman introduced his proposal; President Johnson issued the first Medicare card to former President Truman.

Shortly after implementation of Medicare and Medicaid, how best to address rising health care costs became a staple subject in presidential campaigns. Between 1960 and 1990, the share of the economy (gross domestic product) spent on health care rose by about 30 percent each decade, with the public share of spending growing as well (Exhibit 3). In his 1968 campaign, Richard Nixon raised concerns about medical inflation, and subsequently proposed his own health reform, which included, among other policies, a requirement for employers to offer coverage (i.e., an employer mandate).18 Nixon’s proposal was eclipsed by Watergate, as Jimmy Carter’s health reform promises were tabled by economic concerns. Presidents and candidates in the 1980s set their sights on incremental health reforms.19

In 1991, comprehensive health reform helped Harris Wofford unexpectedly win a Pennsylvania Senate race. In 1992, it ranked as the second most important issue to voters.20 Democratic candidates vied over health reform in the 1992 primaries, with Bill Clinton embracing an employer “pay or play” mandate. George H. W. Bush developed his own plan, which included premium tax credits and health insurance reforms. Five days after his inauguration, President Clinton tasked the first lady, Hillary Clinton, with helping to develop health care legislation in the first 100 days. Yet, mostly because he prioritized economic and trade policy, Clinton did not address a joint session of Congress until September and did not send his bill to Congress until November of 1993. Key stakeholders (including the AMA and the Health Insurance Association of America) initially supported but ultimately opposed the legislation. In September 1994, the Senate Democratic leadership declared it could not pass a bill.21 Less than two months later, Democrats lost their majorities in the House and the Senate, and did not regain them for over a decade. This created a view that comprehensive reform of the complex health system was politically impossible.22 Indeed, presidential candidates in 1996, 2000, and 2004 did not emphasize major health policies. That said, by 2004, health system problems had escalated and, at least on paper, the candidates’ plans addressing them had expanded.23

In 2008, health reform was a dominant issue in the Democratic primaries and platform. Hillary Clinton supported a requirement for people who could afford it to have coverage (i.e., the individual mandate). Barack Obama limited his support to a requirement that all children be insured. Both candidates supported an employer mandate.24 John McCain countered with a plan whose scope exceeded those of many Republican predecessors: it would cap the tax break for employer health benefits and use the savings to fund premium tax credits for the individual market.25 Attention to health reform waned during the general election, as the economy faltered. Even so, the stage was set for a legislative battle. President Obama opened the door to his rivals’ ideas at a White House summit in March 2009.26 After more than a year of effort, he signed the Affordable Care Act into law.27 Obama said that he did so “for all the leaders who took up this cause through the generations — from Teddy Roosevelt to Franklin Roosevelt, from Harry Truman, to Lyndon Johnson, from Bill and Hillary Clinton, to one of the deans who’s been fighting this so long, John Dingell, to Senator Ted Kennedy.”28

Nonetheless, the partisan fight over the ACA extended into the 2012 and 2016 presidential elections. Despite the ACA’s resemblance to his own 2006 reform plan for Massachusetts, Mitt Romney, as the 2012 Republican presidential candidate, vowed to repeal the ACA before its major provisions were implemented; Republicans would subsequently replace it with conservative ideas (mostly to be developed). Four years later, even though the health system landscape had dramatically changed following the ACA’s implementation, the Republicans’ position had not altered.29 Candidate Donald Trump joined his primary rivals in pledging to “repeal and replace Obamacare” (he also embraced unorthodox ideas such as Medicare negotiation for drug prices). Democratic candidate Hillary Clinton proposed a wide array of improvements to the ACA rather than a wholesale replacement of it with a “Medicare for All” single-payer proposal, as did her Democratic primary rival, Bernie Sanders.30 The intra-party differences among primary candidates in 2016 increased attention to the party platforms relative to previous elections.31 But despite continued voter interest (Exhibit 4), differences in health policy were not credited with determining the outcome of the 2016 election.

Setting the Stage for 2020

President Trump’s attempt to fulfill his campaign promise to repeal and replace the ACA dominated the 2017 congressional agenda. In January 2017, the Republican Congress authorized special voting rules toward this effort, while President Obama was still in office. On the day of his inauguration, Trump signed an executive order to reduce the burden of the law as his administration sought its prompt repeal.32 Yet among other factors,33 the lack of a hammered-out, vetted, and agreed-upon replacement plan crippled the Republicans’ progress.34 Speaker Paul Ryan had to take his bill off the House floor on March 24, 2017, because it lacked the necessary votes; the House passed a modified bill on May 4. Senator Mitch McConnell’s multiple attempts in June and July to secure a majority in favor of his version of a health care bill failed on July 26, when Senator John McCain cast the deciding vote against it. In September, Senators Lindsey Graham, Bill Cassidy, Dean Heller, and Ron Johnson failed to get 50 cosponsors for their amendment, the prerequisite for its being brought to the Senate floor.35 The Republicans subsequently turned to tax legislation and, in it, zeroed out the tax assessment associated with the ACA’s individual mandate. At the bill’s signing on December 22, Trump claimed that “Obamacare has been repealed,”36 despite evidence to the contrary.37

A different type of legislative effort began in mid-2017: bipartisan attempts to improve the short-run stability of the ACA’s individual market. This was in part necessitated by the Trump administration’s actions pursuant to the Inauguration Day executive order: reductions in education efforts, marketing funding, and premium tax credits, among others.38 On October 12, 2017, the president signed a second ACA executive order, directing agencies to authorize the sale of health plans subject to fewer regulatory requirements.39 On the same day, his administration halted federal funding for cost-sharing reductions, a form of subsidy, claiming the ACA lacked an appropriation to make such payments. Concerns that these actions would increase premiums, reduce insurer participation, and discourage enrollment prompted coalitions of bipartisan lawmakers to introduce bills. Most notable was a bill by Senators Lamar Alexander and Patty Murray; their proposal, released October 18, 2017, had 12 Republican cosponsors and implicit support from all Democrats, giving it the 60 votes needed in the Senate to overcome a filibuster.40 Yet the version that Senator McConnell ultimately brought to the floor for a vote, in March 2018, included changes that repelled Democrats, preventing its passage.41 Partisans on both sides have blamed this failure, in part, for emerging increases in health insurance premiums.

Indeed, benchmark premiums in the health insurance marketplaces rose by an average of over 30 percent in 2018 and are projected to increase by 15 percent in 2019, largely because of policy changes.42 Some data suggest that the growth in health care costs may be accelerating as well.43 This may have contributed to an increase in the number of uninsured Americans. One survey found that the number of uninsured adults, after falling to a record low in 2016, had risen by about 4 million by early 2018.44 These statistics could heighten candidates’ interest in health policy in 2020.

Public opinion, too, could help health reform gain traction. Tracking polls suggest that concerns about health care persist, with 55 percent of Americans worrying a great deal about the availability and affordability of health care, according to a poll from March 2018.45 Interestingly, while the partisan differences of opinion on the ACA continue, overall support for the ACA has risen, reaching a record high in February 2018 (Exhibit 5).

This concern about health care has entered the 2018 midterm election debate. It is currently a top midterm issue among registered voters, a close second to jobs and the economy.46 Some House Republicans who formerly highlighted their promise to repeal and replace the ACA no longer do so in light of the failed effort of 2017.47 Democrats, in contrast to previous elections, have embraced the ACA, unifying around its defense in the face of Republican “sabotage.”48 The debate also has been rekindled by Trump’s decision to abandon legal defense of key parts of the ACA.49 Regardless of what happens in the courts, this signifies his antipathy toward the law. Barring a midterm surprise, the next Congress is unlikely to succeed where the last one failed. As such, “repeal and replace” would be a repeat promise in Trump’s reelection campaign.

Likely 2020 Campaign Plans

Against this backdrop, presidential primary candidates and the political parties will forge their health care promises, plans, and platforms. Common threads from past elections are likely to be woven into the 2020 debate. The different parties’ views of the balance between markets and government have long defined their health reform proposals.50 Republicans will most likely still be against the ACA as well as uncapped Medicare and Medicaid spending, and for market- and consumer-driven solutions. Democrats will most likely blame Republicans’ deregulation for rising health care costs; defend the ACA, Medicare, and Medicaid; and advocate for a greater role for government in delivering health coverage and setting payment policy. Potential policies for inclusion in candidates’ plans have been introduced in Congress (Exhibit 6). But major questions remain, such as: how will these campaign plans structure choices for individuals and employers, promote efficient and high-quality care, and learn from the experience of local, state, national, and international systems?

Likely Republican Campaign Plan: Replace the ACA with Devolution and Deregulation

President Trump has indicated he will run for reelection in 2020.51 His fiscal year 2019 budget included a proposal “modeled closely after the Graham-Cassidy-Heller-Johnson (GCHJ) bill.” It would repeal federal financing for the ACA’s Medicaid expansion and health insurance marketplaces, using most of the savings for a state block grant for health care services. It would also impose a federal per-enrollee spending cap on the traditional Medicaid program. States could waive the ACA’s insurance reforms.52 The congressional bill also would repeal the employer shared responsibility provision (i.e., the employer mandate) and significantly expand tax breaks for health savings accounts, among other policies.53 The framework for this proposal — repealing parts of the ACA, replacing them with state block grants, reducing regulation, and expanding tax breaks — is similar to the 2016 Republican platform.

Trump may continue to express interest in lowering prescription drug costs. In 2016 and early 2017, he supported letting Medicare negotiate drug prices54 — a policy excluded from the 2016 Republican platform and his proposals as president. His 2019 budget seeks legislation primarily targeting insurers and other intermediaries that often keep a share of negotiated discounts for themselves.55 On May 11, 2018, he released a “blueprint” to tackle drug costs, including additional executive actions and ideas for consideration. Polls suggest that prescription drug costs rank high among health care concerns.56

One policy initiative in the recent Republican platforms but not embraced by the president is Medicare reform. The idea of converting Medicare’s defined benefit into a defined contribution program and raising the eligibility age to 67 was supported by Vice President Mike Pence when he was a member of Congress and by Speaker of the House Paul Ryan.57 Major Medicare changes were excluded from the 2017 ACA repeal and replace proposals. In contrast, versions of Medicaid block grant proposals appeared in various bills, including the GCHJ amendment, as well as numerous Republican presidential platforms.

Historically, presidents running for reelection have limited competition in primaries. Those challengers, by definition, emphasize their differences with the incumbent, which may include policy. It may be that John Kasich will run on maintaining the ACA Medicaid expansion but otherwise reforming the program (his position as governor of Ohio throughout 2017). Or, Rand Paul could campaign on his plan to repeal even more of the ACA than the Republicans’ 2017 bills attempted to do. Incumbents tend to have slimmer campaign platforms than their opponents in general and primary elections, since their budget proposals, other legislative proposals, and executive actions fill the policy space (see Reagan, Clinton, George W. Bush, Obama). Exceptions include George H. W. Bush, who in 1992 developed a plan given voters’ concerns about health; and Nixon, who offered a proposal for health reform at the end of his first term.

Likely Democratic Campaign Plan: Improve the ACA and Add a Public Plan

It is possible and maybe probable that the ultimate Democratic Party platform in 2020 will resemble that of 2016: build on the ACA and include some sort of public plan option. Legislation has been introduced during this congressional session that builds on the law by extending premium tax credits to higher-income marketplace enrollees (e.g., Feinstein, S. 1307), lowering deductibles and copayments for middle-income marketplace enrollees (e.g., Shaheen, S. 1462), providing marketplace insurers with reinsurance (e.g., Carper, S. 1354), and strengthening regulation of private market insurance (e.g., Warren, S. 2582). Some proposals aim to increase enrollment following the effective repeal of the individual mandate, by, for example, raising federal funding for education and outreach, and testing automatic enrollment of potentially eligible uninsured people (e.g., Pallone, H.R. 5155). These proposals would have different effects on health insurance coverage, premiums, and federal budget costs.58

The Democrats will inevitably discuss a public plan in their platform, although the primary contenders will most likely disagree on its scale (e.g., eligibility) and design (e.g., payment rates, benefits).59 In September 2017, Senator Bernie Sanders introduced the Medicare for All Act (S. 1804). It would largely replace private insurance and Medicaid with a Medicare-like program with generous benefits and taxpayer financing. “Medicare for more” proposals have also been introduced: Medicare Part E (Merkley, S. 2708), an option for individuals and small and large businesses; Medicare X (Bennet, S. 1970), which is available starting in areas with little insurance competition or provider shortages; and a Medicare buy-in option, for people ages 50 to 65 (Higgins, H.R. 3748). A Medicaid option (Schatz, S. 2001), similar to Medicare Part E, offers a public plan choice to all privately insured people, aiming to capitalize on the recent popularity of that program. Publicly sponsored insurance plans have long been included in Democratic presidents’ platforms, although the government’s role has ranged from regulating the private plans (Carter, Clinton) to sponsoring them (Truman, Obama). It may be that the candidate who prevails in the primaries will determine whether the Democratic platform becomes “Medicare for all” or “Medicare for more.”

This may be the extent of Medicare policies in the 2020 Democratic platform. Relatively high satisfaction and low cost growth in Medicare have limited Democratic interest in Medicare policy changes in recent years. Similarly, Democrats have not introduced or embraced major reforms of Medicaid. However, the public concern about prescription drug costs has fueled Democratic as well as Republican proposals, some of which target the drug companies (e.g., addressing “predatory pricing,” allowing Medicare rather than prescription drug plans to negotiate the prices for the highest-cost drugs).60

Discussion

Predictions about presidential campaigns have inherent limits, as many experts learned in the 2016 election. Events concerning national security (e.g., conflict), domestic policy (e.g., a recession), or the health system (e.g., a disease outbreak) could alter the policy choices of presidential candidates. New ideas could emerge, or candidates could take unconventional approaches to improving the health system. And, while campaign plans have relevance, the long history of attempts at health reform underscores that by no means are promises preordained.

That said, perennial policies and recent political party differences will likely figure in 2020. Republican presidential candidates, with few exceptions, have adopted a small government approach to health reform: shifting control to states, cutting regulation, preferring tax breaks and block grants over mandatory federal funding, and trusting markets to improve access, affordability, and quality. Democratic presidential candidates have supported a greater government role in the health system, arguing that market solutions are insufficient, and have defended existing programs like Medicare, Medicaid, and, now, the ACA. Some will probably support the government’s taking a primary role in providing coverage given criticism of the efficacy and efficiency of private health insurers. The direction and details of the campaign plans for 2020 will be developed in the coming months and year. Given such plans’ potential to shape the next president’s agenda, now is the time to scrutinize, modify, and generate proposals for health reform.