As the 2020 Democratic primary inches along toward the moment when votes will actually be cast—still more than three months away—healthcare has emerged as the most contested piece of ground. Progressives Bernie Sanders and Elizabeth Warren support Medicare for All, a system in which the federal government, rather than private companies, would provide health insurance to all Americans. Relative moderates like Joe Biden and Pete Buttigieg have gone after M4A for being too expensive and taking away people’s choices. Under fire for being too vague, Warren has promised to explain how she’s going to pay for her version of M4A, and this continued argument promises to figure prominently in the next Democratic debate, just as it has in the previous sparring matches.
But while healthcare is undeniably important, and the differences between the candidates’ healthcare plans are real, a lot of this discussion seems misplaced. It’s a dispute that generates light and heat, but the stakes are deceptively low—the big policy disagreement of the primary is unlikely to affect any real person’s life. In addition to asking big, abstract questions about the specific healthcare system each candidate supports, we should also ask what they would actually do as president to expand access to care and make the current system better in the short term. And then, of course, there’s the question of what they would even be able to do, which is why we need to talk about the Senate.
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Presidents can’t dictate healthcare policy—they need Congress, too
Imagine that Warren or Sanders wins the presidency and decides to make enacting Medicare for All the central priority of their early administration. In such a world, it’s probably safe to assume the Democrats have retained the House, but it will be more difficult for them to take the Senate, which will require them to win seats in multiple red-leaning states. And even if they do have a majority in Congress’s upper chamber, they will be well short of the 60 votes needed under current Senate rules to pass legislation.
Democrats could change those rules so that only a bare majority (or 50 votes, since the vice president breaks ties) is required. Progressives have already advocated for such a move, and Senate Minority Leader Chuck Schumer might be open to it. But even if Democrats are only looking for 50 votes, in a closely divided Senate they need to convince their most moderate members to support Medicare for All. Could a President Sanders persuade West Virginia’s Joe Manchin to back Medicare for All? Or Arizona’s Krysten Sinema? Both are likely swing votes, and both have said they don’t support M4A. So has California’s Dianne Feinstein, who has endorsed Biden.
That’s not to say that it would be much easier to enact a less-disruptive plan like the public option—it’s far from clear that swing votes like Sinema would be on board with that. Passing any piece of healthcare legislation is an incredibly difficult task given the composition of the Senate.
Centrist Democrats have derailed healthcare reform before. In 2009, during the fight over Barack Obama’s Affordable Care Act, a major issue was the public option, which would allow—though not require—people to buy insurance from the government. A lot of progressives and most Democratic senators supported the public option, but Joe Lieberman turned against the idea and it was stripped from the final bill because Democrats needed every vote. It’s easy to see how a different centrist could play the Lieberman role in a Democratic Senate.
In that case, what could a president do without Congress on board?
Even in the likely scenario where Democrats can’t pass healthcare legislation, a Democratic president would still be able to change policy. After the Republicans failed to follow through on their promise to repeal the ACA in 2017, Donald Trump used executive actions to chip away at it, making it harder for people to purchase plans on private marketplaces set up by the ACA, allowing people to buy cheap plans that don’t actually provide much coverage, and letting states try to kick poor people off Medicaid, among other moves. Trump also reduced the tax penalty uninsured people pay to $0—reducing incentives for healthy people to buy insurance and thereby threatening the market for everyone else—and Republicans are supporting an ongoing lawsuit that uses that change to argue that the whole ACA should be struck down.
A Democratic president could use similar tactics to move the system in the opposite direction. Maura Calsyn, a healthcare expert at the Center for American Progress, a left-leaning think tank that has endorsed a version of the public option, said that some of these moves could be immediately reversed. “The Trump administration has removed key information about the ACA on government websites, and has deleted information about applying for coverage from healthcare.gov,” she said. “A Democratic administration could come in and immediately put that information back up. There are other things that a new Democrat in office could do immediately that would set up next year’s open enrollment to be much more successful.” This includes things like lengthening the enrollment period when people can buy ACA plans (which was shortened by Trump) and making sure the website on which they can do that is actually running.
Other actions, like making sure all insurance plans fulfilled original ACA requirements, would have to go through an official rulemaking process and would therefore take longer, but Calsyn anticipates that abolishing “junk plans” that do not meet ACA requirements would be relatively easy since it would just mean reverting to an Obama-era standard.
A Democratic president could go beyond restoring the 2016 status quo by, for instance, standardizing the options offered on the ACA marketplaces to give consumers clearer choices. Making the federal government an “active purchaser,” the technical term for that tweak, is an option favored by some advocates and something that some states, including Massachusetts and California, have already done.
It’s likely that any Democrat would do all of this on day one of their presidency, regardless of what they thought of Medicare for All or the public option.
In the end, it’s silly for the Democratic candidates to be sparring over their healthcare differences.
During a televised debate in July, long-shot Democratic candidate John Delaney went on a tear against M4A and other left-wing policies, calling them “fairy tale economics.” That led to Warren effectively ethering him onstage, but what was striking about this exchange was that Delaney’s own universal healthcare plan is actually pretty progressive. He advocates for the government providing bare-bones insurance to everyone under 65 and allowing people to purchase supplemental private insurance. He chose to portray that as a moderate alternative to M4A, but it’s more ambitious than nearly any elected Democrat (Sanders excepted, of course) was being just a few years ago, and more ambitious than the plans of some of his fellow candidates.
That moment showed how far left the Democratic Party has gone on healthcare, thanks in part to the ongoing and loud advocacy of Sanders. Even the most staunch moderates in the race, Biden and Buttigieg, have embraced a public option, and it’s worth noting that this “centrist” policy is opposed by the right on the grounds that if the government was selling health insurance, private insurers couldn’t compete. It also calls for far more government involvement in the insurance market than any proposal from the GOP.
Calsyn thinks that the conflict between M4A-supporting candidates and their moderate opponents is at least partially ginned up by the media. “The press has really wanted to create a Medicare for All versus everything else framework for the Democratic debate, but there are so many other steps and pieces that all of the candidates have mentioned they’re going to do,” she said. “The far bigger chasm is really between Republicans, who want to increase the number of uninsured and shift costs to consumers and make it more difficult to receive comprehensive affordable healthcare, and Democrats, who are all working on ways to bolster coverage and lower costs. There’s far more in common than the debates would lead voters to believe.”
A lot of the focus on healthcare in the primary can be explained by the issue being a proxy for the candidates’ views on the power of government. Supporting Medicare for All is a way to signal that you think the government is responsible for the health of its citizens, that the government can be an enormous force for good, and that certain industries (in this case, health insurance) are detrimental to society and should simply be wiped out. It’s a philosophical question, not a policy one: Do you think that a much better world is possible through politics? Can we alter the parts of the United States that are objectively a failure, like the healthcare system?
But as important as those fundamental questions are, if the media and the candidates are going to spend a lot of time on healthcare, it seems like there should be other topics on the table. Debate moderators could ask candidates not to have the same argument over M4A, but to discuss whether they would even prioritize healthcare in the first place, given the political complications. Moderators could also ask what the candidates would do if they couldn’t pass their preferred healthcare plans, or what they think the president can do through executive orders to fix the U.S. health system. That might shed some light on how candidates are thinking about specific small changes that would improve people’s lives.
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