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.