Iowa Democrats in a rural, Republican-leaning congressional district will take to the polls Tuesday to weigh in on the party's warring healthcare proposals: allowing the public to buy into Medicare or providing healthcare for all Americans.
Cindy Axne, a longtime state official who recently won official backing from the Des Moines Register in the three-way Democratic primary for the southwest Iowa seat held for two terms by GOP Rep. David Young, wants to allow people to buy coverage from Medicaid or Medicare, known as the public option. She is neck-and-neck with Eddie Mauro, who says he supports public coverage, private coverage or a combination of the two as long as there's expanded access. The third contender, Bernie Sanders-endorsed Pete D'Alessandro, wants single-payer but he has lagged far behind the other two in polling.
They each have a big point to make on healthcare—one that Democrats are pushing across the country. Incumbent Young reluctantly voted with his fellow Republicans last year in the GOP push to repeal and replace Obamacare. The Democratic candidates have argued that Young wanted to take away healthcare in a state where coverage is increasingly precarious.
Iowa's Obamacare markets have long been notoriously messy and observers say the Trump administration's latest tranche of policies will make them worse, giving the 3rd District's candidates a platform to promote broader access and lower costs.
"It's a mess down here in the state," Axne said. "Healthcare is literally the biggest issue we're facing here in Iowa, and the No. 1 issue on the trail."
When it comes to the public option, she added, Iowans are "really open."
Sitting congressional Democrats are increasingly comfortable with the idea of a public option. Over the past year, lawmakers have proposed several bills involving public option ideas. They counter the "Medicare for all" proposal by Vermont's liberal independent Sen. Bernie Sanders that critics have panned as impractical and costly while shifting the majority of Americans off their employer coverage.
Current polling for both these options track in their favor at a time when Obamacare has never been more popular.
A recent Kaiser Health Tracking Poll found about 75% of the overall public would support a public option, although analysts noted that it is unclear whether this favorability would hold if the proposals were up for serious consideration; past polling has shown people can be swayed considerably. This compares to 59% support for "Medicare for all."
When congressional Democrats had a public option on the table in the early stages of Obamacare, polling varied wildly with Kaiser showing 65% public support and Rasmussen Reports showing just 41% public support.
Democratic constituents appear to be divided when it comes to building up Obamacare or focusing on a single-payer system, the Kaiser poll found. About 46% want lawmakers to improve Obamacare and 48% want them to work on single payer.
Democratic candidates are navigating this line carefully, building their bigger message on top of the promise to reinforce Obamacare. However individual market stabilization talks between Republicans and Democrats fell apart earlier this year, and it is unclear whether they would be able to be revived again even if Democrats take the House.
As states like Nevada and New Mexico consider their own buy-in approaches for coverage, industry stakeholders are taking a closer look at the policy behind the public option since it may emerge on the state level before Congress could take action. They warn however that lawmakers should show caution in bringing a state policy to the national level.
A study from the Urban Institute earlier this year warned a buy-in could be complicated—particularly in states that still run fee-for-service Medicaid. This is most common in rural states or regions. The brief also points out that many states still haven't expanded Medicaid, which belies the idea that Congress could gather enough political support to pass this kind of measure.
Francis Rienzo of Medicaid Health Plans of America, the trade group representing for-profit Medicaid managed-care plans, said ultimately it's hard to weigh in on the feasibility of such a plan without seeing the details, but it's sure to be complicated.
"When we look at what's out there, it fits into two buckets," Rienzo said. "You're getting money to buy coverage in the exchange, a Medicaid insurance product, or you're buying into program with some kind of subsidies. Or, the subsidies aren't part of it. Then add an infinite number of permutations. In either scenario, there are a lot of challenges from a program perspective."
Ultimately, he said, Medicaid as a program was not created for people to buy into it.
"But it could get interesting," Rienzo said. "We're just watching."