I have long predicted (Goodbye Obamacare? More like hello single payer) that if the GOP succeeds in undermining the Affordable Care Act it could hasten the move toward single-payer. Well, the undermining has been reasonably successful. And I think 2019 will shape up as the year that formerly taboo proposals like single payer health insurance go mainstream.
Despite what opponents say now, the Affordable Care Act was a moderate bill that sought to work within the existing system and incorporate bipartisan elements, including 188 Republican amendments. Before the individual mandate was pilloried as a threat to freedom, it was upheld as a virtuous plan of personal responsibility by the Heritage Foundation and American Enterprise Institute. Democrats tried to get Republican votes for the ACA. It was a GOP strategy to refuse.
When Republicans tried Repeal and Replace, they didn’t even pretend to include Democrats in their solutions. And of course, Candidate Trump’s promise to replace Obamacare with “something great” was a lot of nonsense.
With all this history, mainstream Democrats are feeling freer to jump to more radical and comprehensive proposals. After all, the ACA was complicated, messy, and full of compromises largely because of its attempt to be bipartisan and incrementally change the existing system. Why not jump to something purer and simpler that doesn’t need GOP input?
As the race for President gets underway, Democrats will start to feel their way on healthcare. Defense of the ACA is a pretty modest, minimum requirement. You can expect to hear calls for Medicare for All, which is a way to offer a popular benefit to more people without creating a whole new system.
But I’m also on the lookout for more radical approaches and it looks like we won’t even need to wait for the Presidential campaign to heat up in order to hear about them. Newly installed California Governor Gavin Newsom is ready to take on Donald Trump directly, calling for a single-payer system, mandatory coverage, expanding access for undocumented immigrants, and regulating drug prices. California is holding an early primary this cycle, so the ideas Newsom is setting out now will influence the debate.
I’d like to see serious discussion of Medicaid for All (rather than Medicare for All). Medicaid pays providers and drugmakers less and is also more comprehensive than Medicaid and better suited for younger adults and children. It’s a more affordable way to provide coverage, provides discretion to the states, and would drive down overall costs by driving down reimbursement rates. Medicaid for All would be a mixed bag for providers and pharma, so would unleash a very passionate debate.
A likely compromise is to offer Medicaid to everyone as a fallback, while retaining commercial and Medicare coverage for those who are eligible and want it.