What Democrats could do on healthcare if Kamala Harris wins

The Democratic National Convention kicks off Monday in an atmosphere of renewed optimism for the party and a new candidate atop its ticket. One thing that won’t be entirely new is the trajectory of health policy should Vice President Kamala Harris and Minnesota Gov. Tim Walz win the White House on Election Day.

The top-line item, healthcare analysts and policy experts predict, will still be reproductive healthcare and abortion, which Democrats up and down the ballot are emphasizing and which promises to be a recurring topic at the DNC in Chicago, which runs through Thursday.

Close after that will be health policies that reinforce steps taken under President Joe Biden, such as preserving enhanced health insurance exchange subsidies that expire at the end of 2025 and pushing ahead with Medicare drug price negotiations like those announced last week.

Harris, the Democratic presidential nominee, previewed her healthcare agenda Friday, which includes extending the exchange subsidies, expanding Medicare drug price negotiations, targeting drugmakers and pharmacy benefit managers to reduce pharmaceutical costs, and forgiving medical debt.

The Harris platform contrasts sharply with that of her opponent, former president and current Republican nominee Donald Trump, who has repeatedly called for repealing the Affordable Care Act of 2010 and supports the 2022 Supreme Court ruling that ended a national right to abortion.

Related: GOP offers hints on healthcare agenda as RNC kicks off

Despite continuity between the Biden record and the Harris agenda, there would likely be changes in focus compared to the current administration, particularly an increased emphasis on reproductive health, including maternal health bills Harris backed during her term in the Senate and in vitro fertilization, and perhaps an even tougher approach to antitrust enforcement, given Harris' record as attorney general of California.

The Congress factor

The big wild card is who's in charge on Capitol Hill next year.

“We have to see what the makeup of Congress is,” said Debra Curtis, a lobbyist at McDermott+ who worked as a Democratic congressional healthcare aide for more than 20 years. “All of that is going to play a factor in what can or could or might happen.”

With a Democratic House and Senate, Harris could pursue all of her healthcare proposals, starting with insurance subsidies, Medicare drug pricing policies, and reproductive health measures. If Republicans control at least one chamber of Congress, the path forward for her agenda is much less clear.

Harris would aim to preserve the gains President Barack Obama and Biden made in expanding healthcare coverage through the Affordable Care Act of 2010. That would require extending the enhanced tax credits Biden enacted, which drove health insurance exchange enrollment to a record high of 21 million this year. Those larger subsidies will expire at the end of 2025 without new legislation. Republicans have opposed making the tax credits more generous.

“There's going to be a debate about what happens to the premium tax credits in the marketplaces, and that's a huge issue with big stakes,” said Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities.

A Democratic trifecta would enable Harris to advance budget-related bills through the Senate on majority votes not subject to GOP filibusters, which require 60 votes to end.

The legislative mechanism known as budget reconciliation allows simple majority approval of bills that modify federal revenue or spending and has frequently been used to break logjams in the upper chamber. Biden's signature domestic policy achievement, the Inflation Reduction Act of 2022, was a budget reconciliation bill, as was Trump's Tax Cuts and Jobs Act of 2017.

The exchange subsidies would fit into budget reconciliation legislation, as would proposals to offer health coverage to low-income people living in the 10 states that have not expanded Medicaid under the ACA and to broaden Medicare drug negotiations to include more medications.

Bully pulpit, antitrust

Regardless of the political makeup of Congress, the president has enormous power to shape healthcare policy through executive actions. Should Harris win but face a divided or Republican-controlled Congress, she is most likely to double down on priorities that are already in law, or simply use the bully pulpit, Curtis said.

“You will see affordability and drug prices continue to be an incredibly important issue for her,” Curtis said.

Without a cooperative Congress, Harris could rigorously enforce rules already on the books capping costs for consumers, and continue to defend against lawsuits challenging Medicare drug price negotiations while ensuring that initiative rolls out smoothly.

Keeping, and even ramping up, the Biden administration's antitrust enforcement through the Federal Trade Commission and the Justice Department would be another likely tack. Before Harris was elected to the Senate from California, she was the state’s attorney general, and was involved in several notable healthcare cases.

Those included leading a dozen states to join with the Justice Department to block a proposed $48 billion merger between Cigna and Anthem (now known as Elevance Health) in 2016. In 2014, she joined with 16 states to back the FTC in blocking Boise, Idaho-based St. Luke's Health System from acquiring the state’s largest physician group, Nampa-based Saltzer Medical Group.

In 2012, Harris launched an investigation into whether mergers between hospitals and physician groups were leading to higher costs. That ultimately led to a lawsuit against Sacramento, California-based Sutter Health alleging anticompetitive behavior. Sutter Health settled the case for $575 million during the term of Harris' successor as state attorney general, Xavier Becerra (D), who is now Biden's Health and Human Services secretary.

The Biden administration has already escalated antitrust enforcement, challenging mergers, investigating pharmacy benefit managers and group purchasing organizations, and broadly investigating anticompetitive behavior in healthcare.

“The Biden administration has been front and center looking at those issues, but I think she brings a lens that is more experienced, and with a lot more depth on that topic than Biden did personally,” Curtis said.

Despite the wide distance between Democrats and Republicans on health policy, promoting competition and lowering costs could generate some populist GOP support on Capitol Hill. Congressional Republicans have recently bemoaned the effects of vertical integration in healthcare on patients and demonstrated an interest in tackling the issue.

“It does fit, in a sense, with the MAGA take on the power structure and some of that power structure in the corporate world. It's not just the evil 'Deep State,'" said Mark Peterson, a University of California, Los Angeles School of Law professor who teaches public policy at the UCLA Meyer and Renee Luskin School of Public Affairs.

Harris also may choose to promote policies that would boost maternal healthcare and home care, said Larry Levitt, executive vice president for health policy at the research institution KFF.

“Harris has taken the lead on caregiving issues, and I wouldn’t be surprised to see further proposals from her on home- and community-based long-term care,” Levitt said.

Republicans have supported initiatives such as extending current hospital-at-home rules for five years, perhaps suggesting some common ground, although Biden was unable to implement his goal to invest hundreds of billions of dollars into home- and community-based services.

Medicare for All?

Prior to her brief campaign for the Democratic presidential nomination in 2020, Harris co-sponsored legislation from Sen. Bernie Sanders (I-Vt.) to create a single-payer, "Medicare for All" system that would replace private health insurance. Before dropping out of that race and endorsing single-payer opponent Biden, Harris distanced herself from the plan.

That hasn't stopped Republicans from tying her to Medicare for All, however. A news release from Trump campaign Friday described the her healthcare agenda as "Bernie Sanders' elimination of private healthcare," for instance.

Harris supported Senate bills to create a government-run public option insurance plan that would be available alongside private plans, and Walz favors establishing one on MNSure, Minnesota's health insurance exchange. Biden likewise proposed a public option in the 2020 presidential election.

Nevertheless, Harris is unlikely to revisit single-payer healthcare, Curtis said.

"I don't see all of a sudden in America a turn to Medicare for All," Curtis said. "The focus is really going to be on: What are the steps we can take in our health system to improve affordability and make sure that people can get the care that they need?"

And even if Harris were interested, it would take a "transformative" result on Election Day that handed Democrats "substantial" majorities in both chambers to even raise the possibility of such a dramatic change to the healthcare system, Peterson said.

No one expects that.