As the 2020 elections near, federal and state policymakers are sharpening their plans for healthcare reform—an issue that proved important to voters in the 2018 midterm elections and is on track to be a core issue in the 2020 race. Next week, Democratic presidential hopefuls will take the stage in the first televised Democratic primary debates, where they will seek to differentiate their healthcare reform views in the crowded race. Democratic presidential candidates have largely aligned on the goal of universal coverage, though they vary on proposals for achieving that goal, as shown in Figure 1 (and further described below).
At this juncture, Republicans’ plans are less clear. In light of many pundits’ belief that Republican efforts to repeal and replace the Affordable Care Act (ACA) contributed to their loss of House control in the 2018 midterms, the White House and Republican members of Congress have avoided broad healthcare reform debates this session. But the pressure to announce their plans will grow as the 2020 election nears, and will heighten as ongoing litigation over the constitutionality of the ACA—which the Department of Justice (DOJ) decided not to defend—is back in the spotlight this summer. White House Acting Chief of Staff Mick Mulvaney has said that the White House’s healthcare plan will be made available “fairly shortly,”1 and just this week, the President indicated that he “already ha[s] the concept of the plan.” With the President seeking reelection in 2020, the Republican Party’s healthcare position will likely be defined by the actions of the administration.
Figure 1. Democratic Presidential Candidates’ Healthcare Reform Positions2
Drawing attention to Democrats’ proposals, the House Ways and Means Committee held a hearing last week to discuss “Pathways to Universal Health Coverage.”
The Democratic proposals discussed during the hearing build on one common theme—making strides toward achieving universal healthcare coverage—but they vary considerably in how they would achieve that goal. So far, Democratic proposals fall into the following five categories:3
- Single Payer. Also referred to as “Medicare for All,” the federal government provides coverage to all United States residents, subsuming existing coverage options, including employer-sponsored insurance (ESI) and Medicaid.4
- “Medicare” Expansion. The federal government would create a new Medicare program that incorporates federal healthcare programs—including the existing Medicare program, the individual insurance market, Medicaid and the Children’s Health Insurance Program (CHIP)—into a single program, to which enrollees would contribute a premium for coverage. Employers could choose to participate or opt out and maintain ESI.5
- Targeted Medicare Buy-In. The federal government would allow legal residents between 50 and 64 years old who are currently ineligible for Medicare to purchase Medicare coverage through “buying in.”6
- Federal Public Option. The federal government would offer a qualified health plan (QHP) on the Marketplace, leveraging Medicare’s infrastructure.7
- Federal Support for State-Based Reforms. The federal government would support state-based coverage programs through new authority and financing mechanisms, and/or provide states with flexibilities such as by giving them the authority to “tie” provider participation in state-sponsored plans to Medicare participation (in order to encourage the development of adequate provider networks).8
During the hearing, many members voiced partisan support for—or opposition to—the Medicare for All proposal and increasing the federal government’s role in healthcare. Although Democrats have not coalesced around a single approach, they were unified in their focus on increasing coverage, and many Democratic members underscored their support for strengthening the ACA and utilizing Medicare as a tool for achieving that goal.
Chiquita Brooks-LaSure, managing director at Manatt Health, testified during the hearing, alongside other healthcare experts and a patient advocate.9 Her remarks focused on the subset of proposals that would expand government programs while leaving the commercial insurance markets and other facets of the existing healthcare system in place. Ms. Brooks-LaSure pointed to federal legislation to support state-based innovations as a “pragmatic way to move forward government health reforms in the short term and [an option that] could serve as an example for future collaborative national reform.”
1 Diamond, D. “Mulvaney: GOP will unveil health plan ‘fairly shortly.’” POLITICO. April 2019.
2 Only Democratic presidential candidates with >1% in average polls, according to Real Clear Politics as of June 11, are included.
If a candidate has published a specific policy plan, it is listed below.
3 For more information about these proposed models, see Manatt Health’s paper The Landscape of Federal and State Healthcare Buy-In Models.
4 Medicare for All Act of 2019 (Sanders; S. 1129); Medicare for All Act of 2019 (Jayapal; H. 1384).
5 Medicare for America Act of 2019 (DeLauro/Schakowsky; H. 2452).
6 Medicare at 50 Act (Stabenow; S. 470); Medicare Buy-In and Health Care Stabilization Act of 2019 (Higgins; H. 1346).
7 Keeping Health Insurance Affordable Act of 2019 (Cardin; S. 3); Choose Medicare Act (Merkley/Richmond; S. 1261/H. 2463); Medicare-X Choice Act of 2019 (Bennet and Kaine/Delgado; S. 981/H. 2000); The CHOICE Act (Schakowsky/Whitehouse; H. 2085/S. 1033).
8 The current bill facilitated federal tax credits and federal Medicaid match dollars for state programs. State Public Option Act (Schatz/Luján; S. 489/H. 1277).
9 Other hearing witnesses included Dr. Donald Berwick, resident emeritus and senior fellow at the Institute for Healthcare Improvement and former administrator of the Centers for Medicare & Medicaid Services (CMS); Pam MacEwan, CEO of Washington State’s Marketplace, “Washington Healthplanfinder”; Rebecca Wood, patient advocate and mother from Boston; and Tricia Neuman, director of the program on Medicare policy at the Kaiser Family Foundation.