For the better part of the year, the Democratic field has debated the best way to expand health care access to all Americans. Is a public option enough? How can Medicare for All be fully implemented? Should private insurance still play a role?
The first real health care battle, however, should any of them get sworn in to the presidency in 2021, may very well be simply saving the protections in the current system we have.
Back in mid-December, the Republican-backed lawsuit to dismantle the ACA got its decision from the 5th Circuit Court of Appeals: the individual mandate was unconstitutional. The court then remanded the case back to the lower district court judge in Texas that had already ruled the entire ACA unconstitutional, arguing that the individual mandate was not “severable” from the rest of the law.
The 5th Circuit asked him to comb through the law and better explain which parts, even if it was still all of the ACA, must go along with the mandate. Even if the entire law isn’t wiped out, there’s real concern that the preexisting conditions protections could be tossed out.
By kicking it back to Judge Reed O’Connor, a right-wing judge often tasked with carrying out conservative legal wishes, it delayed any final decision or Supreme Court battle, also saving Americans’ insurance in the short-term.
But that was actually all part of the plan. It’s now unlikely the ACA will face any major disruption until after the 2020 election, sparing Donald Trump and Republicans the full consequences of their highly-unpopular actions.
In that way, it truly is a cynical plan, aiming to wait to destroy the ACA and eliminate coverage for millions of Americans until after 2020, perhaps once a Democrat is in the Oval Office. Voters locked into conservative media and social media bubbles will certainly be told they lost their coverage because of the new Democrat’s policies, rather than the little-known Republican lawsuit.
Whatever Judge O’Connor decides will almost certainly get put on hold as the case works it way back to the Supreme Court, or California Attorney General Xavier Becerra, leading the states defending the ACA, could try to get it there sooner. The ACA’s final fate could easily come down to whether Trump gets to put another justice on the Supreme Court before then.
Regardless of how that legal battle eventually turns out, it all makes it very likely that most of the health care headlines in 2021 will focus on what happens with the ACA. Any further eroding of the law’s provisions could throw the entire country’s health care system into chaos, as the health care news site Health Care Dive explains.
“Indeed, if the invalidation of the law stands, it would spell the end for Medicaid expansion, end coverage for those with pre-existing conditions, terminate certain free preventive health services, knock young adults off their parents’ health plans, lead to the reopening of the Medicare drug donut hole, end the biosimilar approval pathway through the FDA, and cut the Center for Medicare and Medicaid Innovation which has been pushing some of the administration’s current health priorities, including new payment models for healthcare services,” wrote Dana Elfin.
Even the continuing legal limbo of the ACA has made some insurers think twice about engaging on the exchange.
For those candidates wishing to expand the ACA through a public option or to allow anyone to jump on Medicare, such a disruption would throw those plans into doubt. And for any Democrat’s health care proposal, it could take years to start implementation while millions are getting kicked off their plans.
Throughout this primary, no candidate has really laid out a foolproof way to actually get a new, major piece of health care legislation passed through a divided Washington. Most favor ending the filibuster, but a Democratic Senate majority would still be necessary to pass even modest reform. A Medicare for All plan would require convincing a sizable part of the Democratic Senate caucus that isn’t yet on board.
It is certainly possible that a new president could usher in some new kind of politics in the country that transcends today’s gridlock.
Sanders is arguing he’d bring about a full-on revolution, activating the nation’s working class in a way never seen before to pressure their elected leaders. As he said in April in Iowa, that could convince even Joni Ernst and Chuck Grassley to back something like a $15/hour minimum wage… if Iowans wrote them enough letters.
But it is more likely, given recent history, that it will not.
That means implementing any of the Democratic contenders’ biggest health care reforms could be a multi-year process at best.
Some on the left might see this Republican effort to eliminate the ACA as an opportunity, demonstrating that the private insurance industry will simply never be fixed and Congress can’t adequately regulate it, so let’s just start all over. Americans will be outraged over health care more than ever before, making it the best opportunity to make massive change. Forget saving the ACA, let’s focus on a full single-payer system.
But that’s a dangerous game to play.
For all the serious problems that remain in today’s health care system, the ACA still has literally saved the lives of hundreds of thousands of people. Going back to the old rules, where you can be denied coverage for preexisting conditions, or losing the Medicaid expansion, possibly for an extended amount of time while Democrats fight for a massive overhaul, is risky for real people.
Of course, that’s all just theorizing. After Trump’s election, who knows what American politics may look like after his fall.
The important thing to consider, however, is that a new Democratic administration’s actual, most immediate challenge on health care may be simply preserving what we already have. Just as Barack Obama’s first months were complicated by the banking crisis, so too could the next president’s top priorities get sidetracked for fixing new, immediate problems.
And we all know that any fallout from further weakening of the ACA will be cynically used by Republicans to blame Democrats politically for the mess if they’re in the White House.
The Democrats running for president need a plan for that, too.
by Pat Rynard