A New Strategy for Health Care: Looking beyond Trump, Democrats Ought to Focus on Opening Medicare to People at Age 50 and Capping Excessive Health-Care Prices

By Starr, Paul | The American Prospect, Winter 2018 | Go to article overview

A New Strategy for Health Care: Looking beyond Trump, Democrats Ought to Focus on Opening Medicare to People at Age 50 and Capping Excessive Health-Care Prices


Starr, Paul, The American Prospect


With the Trump era only a year old and its full impact on health policy as yet unclear, it may seem premature to discuss what ought to come next. But, driven by new enthusiasm among progressives for Bernie Sanders's single-payer plan, the debate has already begun, and if the past is any indication, supporters of reform will turn to proposals long in gestation when they are finally able to act.

When that time comes, Democrats don't want to discover they have locked themselves into commitments on health care that they cannot fulfill, just as Donald Trump and Republicans did in 2016. Democrats are justifiably angry today about the Republican efforts to sabotage the Affordable Care Act and cut Medicaid that have put health care for millions of people in jeopardy. Supporters of a universal system also have good reason to believe that the ACA was too limited and a stronger government role is necessary. But going to the opposite extreme and nationalizing health insurance has its own problems. Even by Sanders's own estimate his plan would require a larger increase in federal taxes than the United States has ever had in peacetime. For that reason alone (and there are others), Democrats need to look at a broader menu of alternatives.

So, imagine it is January 2021, and a Democrat is ready to assume office as president along with a new Democratic Congress: What priority should health care get, and what policies should a new administration push for?

In Trump's wake, many other legitimate concerns will be clamoring for attention and resources. For four years, the Trump administration will have neglected and in some cases aggravated America's real problems, including economic inequality and insecurity, climate change, and the decaying public infrastructure that Trump shows no signs of fixing. The two previous Democratic presidents made health care their top priority for reform in their first year. Although Bill Clinton failed to pass his Health Security Act, Barack Obama succeeded in passing the ACA. But both of them faced a backlash driven in part by their health policies, lost Democratic congressional majorities after two years, and from then on faced severe limits on what they could accomplish.

I supported Clinton's and Obama's decisions to make health care the early focus of reform in their presidencies, but I'd be hard-pressed to make that argument a third time. That's not to say the Democrats' presidential candidate in 2020 should ignore or downplay health care. The Trump era's damage to national health policy will call for an answer, and the party's primary voters care intensely about the answer their nominee will give. Democrats, however, ought to learn from experience and focus on health-care priorities that make sense as both policy and politics and build popular support over time. Those priorities will have to deal with core concerns about health care yet not absorb every last dollar of revenue a new administration might hope to raise.

Repairing whatever is left of the ACA, if anything is left, will be important but insufficient. Although the ACA has gained in popularity since Trump's election, the law's limitations have also become increasingly apparent. A new Democratic administration should focus on one or two signature health-care proposals that advance the longterm objectives of universal coverage and cost control and respond to people who have insurance but still face financial stress from medical bills. Two ideas could meet these criteria: making available a new Medicare plan for people aged 50 to 64--a program I call "Midlife Medicare"--and directly attacking America's excessive health-care prices. Although the two ideas are independent, they're closely related, since attacking prices also involves an extension of Medicare, in this case the extension of Medicare rates to out-of-network providers in private insurance.

LIMITS OF THE ACA

Advocates for broader access to health care have rightly defended the ACA from Republican attacks, but facing up to its limits is crucial for figuring out what to do next. …

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