Boost Obamacare or push for single-payer? Democrats face tough decisions on the road to 2020

The act of defending the Affordable Care Act helped Democrats wrest back control of the House of Representatives in November. But in the run-up to the 2020 elections, holding steady may not be enough to prevent intraparty dissension over Medicare for All.

But proponents of Medicare for All, the slogan for a single-payer approach brought to the mainstream by Sen. Bernie Sanders (I-Vt.), expect the status quo to fuel their policy as healthcare industry profits soar and public disgust over high costs mounts.

“I think there's already intense pressure for” Medicare for All, said Democratic Rep. Ro Khanna, the California progressive who is pushing hard for a single-payer program. “Premiums are already rising, people aren't happy with the coverage in many cases. There's already this cry for a dramatic fix.”

Wendell Potter, a former Cigna executive who has been pushing for single-payer for a more than a decade, agrees. “The more healthcare costs go up, the more insurers can jack up rates,” he said. “The current structure in place is throwing more money at an inefficient system.”

Potter was referring to the architecture of the ACA subsidies, which are central to the goal of broad coverage as individual market premiums climb.

For people who qualify for federal assistance, these rates don't matter as much because the higher their premiums, the more the government pays on their behalf. Since 2014, when the ACA went into effect, the government is spending 114% more in subsidies.

But for people who don't qualify for subsidies, individual market premiums can be too high to justify for those who aren't sick enough to need the coverage—thwarting efforts to expand the risk pool.

Republicans' answer—in the wake of their failed repeal-and-replace attempts—has been to push more options for people to buy coverage outside the exchange market. The Trump administration has expanded access to plans that don't comply with the ACA. The mainline Democratic answer, outlined in proposals introduced last year, is to expand the subsidies.

This year, House Democratic committee leaders are looking at options to boost the ACA: Earlier this month the first key meeting focused on bills to restore outreach and marketing funds and counter Trump administration regulatory actions like expansion of short-term health plans.

But plenty of Democrats are antsy for more. House Speaker Nancy Pelosi (D-Calif.) promised to give time to the Medicare for All legislation from progressive Rep. Pramila Jayapal of Washington state. She also promised the same to a slate of Democratic lawmakers' policies on adding some form of public option. These include a Medicare-at-50 buy-in, a universal Medicare buy-in called Medicare X, and a bill to authorize Medicaid buy-in at the state level.

Giving room to all the proposals could dilute the pressure to go to a single-payer, but it could also hurt the chances for any one proposal to gain an edge. And healthcare reform hard-liners would rather go straight to single-payer.

“Unless the public option operates exactly like a Medicare plan, giving the public option the ability to set rates with hospitals, for example, it would be doomed to fail,” said Potter, who believes the public option is another way to pour more money into the existing system without guarantee of success.

The healthcare industry is also just as opposed to a public option as it is to single-payer.

That's apparent in the strategy of the broad industry coalition Partnership for America's Health Care Future. The group, which marries a broad swath of usually-at-odds industry heavyweights—from insurers to hospitals to manufacturers—has launched a six-figure messaging campaign to counter Medicare for All. Lauren Crawford Shaver of the firm Forbes Tate Partners, who leads the partnership as its executive director, lumps all the buy-in proposals as a “one-size-fits-all-solution” similar to single-payer.

But others, and not just industry lobbyists, view a public option as a gateway to single-payer and think it's the best way to get there. They include lawmakers who still mourn the fact that a public option didn't end up in the ACA.

“We had a public option—a not-for-profit, national exchange public option, which I think most people would have gravitated to, and that would have paved the way to Medicare for All or single-payer because people would have said, 'Hey, this is better, this is cheaper, and I get better coverage,' ” said Rep. Peter DeFazio (D-Ore.). He has supported a public-option bill ever since the ACA passed.

Sen. Chris Murphy (D-Conn.) agreed, although he said he's keeping his powder dry on the issue until Democrats have the White House and can move something forward. “I hope that all the 2020 candidates look at a robust, universal Medicare buy-in,” he said. “I think it would get you to a single-payer system faster than an immediate legislative prescription of private insurance.”

In appealing to the Democrats' moderate wing, the healthcare industry is relying on the electoral maps of 2018 and 2020 almost as totems to ward off momentum for single-payer and focus instead on more industry-friendly and less controversial ACA fixes. That approach has the support of the moderate New Democrat Coalition, now more than 100 members strong, and the group's centrist healthcare task force. (The progressive Medicare for All caucus has nearly 80 members.)

“I think realistically if you're looking at the House, Democrats know that in order to protect their seats in 2020 we absolutely need to keep a centrist, moderate message,” one lobbyist said. She noted that the Democratic House pickups from 2018 track with the Electoral College map the party needs to win for 2020: largely moderate districts that could easily swing red.

Another hospital lobbyist said that after many decades of talk about single-payer, she still sees it as aspirational. “It's still really a trial balloon that could be popped if the GOP messages it quickly and well,” she said.

Even so, Democratic lawmakers, strategists and industry are keenly aware the status quo may not be enough to assuage the public. Across both parties on Capitol Hill, public unrest over healthcare costs and other issues is driving the legislative push to end surprise medical billing and address high drug prices.

“What people want immediately is to reduce their costs—their out-of-pocket costs, co-pays and premiums,” said Brad Woodhouse, executive director of Protect Our Care, which conducts extensive polling and worked hard to push Democrats' 2018 healthcare message. “They particularly want additional coverage—so they want to see coverage expanded to more people. Then they want the coverage protections enhanced and further protected.

But what's next is still a battle for public opinion. A Kaiser Family Foundation poll from January showed how support for a single-payer program fluctuates wildly depending on how the questions are framed. As lawmakers waffle in Washington, Medicare for All proponents and opponents are taking their campaigns to the public.

As the messaging heats up, the array of public options on the table alongside Medicare for All is allowing Democratic presidential hopefuls to play it safe as they test the waters.

Sen. Elizabeth Warren (D-Mass.) is a case in point. After fellow presidential contender Sen. Kamala Harris (D-Calif.) made headlines by proposing eliminating private insurance, Warren fell back on her support for the ACA and policies to lower drug prices and improve insurer transparency.

But regarding what's next in terms of coverage, given that she co-sponsored Sanders' Medicare for All bill in the last Congress, she declined to take a side. “There are a lot of options on the table,” Warren said. “I'm really glad Democrats are talking about this.”