Getting Ready for Health Reform 2020: What Past Presidential Campaigns Can Teach Us

By Jeanne M. Lambrew
The Commonwealth Fund, June 26, 2018


Issue: The candidates for the 2020 presidential election are likely to emerge within a year, along with their campaign plans. Such plans will include, if not feature, health policy proposals, given this issue’s general significance as well as the ongoing debate over the Affordable Care Act.

Goal: To explain why campaign plans matter, review the health policy components of past presidential campaign platforms, and discuss the likely 2020 campaign health reform plans.

Methods: Review of relevant reports, data, party platforms, and policy documents.

Findings and Conclusions: Proposals related to health care have grown in scope in both parties’ presidential platforms over the past century and affect both agendas and assessments of a president’s success. Continued controversy over the Affordable Care Act, potential reversals in gains in coverage and affordability, and voters’ concern suggest a central role for health policy in the 2020 election. Republicans will most likely continue to advance devolution, deregulation, and capped federal financing, while Democrats will likely overlay their support of the Affordable Care Act with some type of Medicare-based public plan option. The plans’ contours and specifics will be developed in the months ahead.

Likely Republican Campaign Plan: Replace the ACA with Devolution and Deregulation

President Trump has indicated he will run for reelection in 2020. His fiscal year 2019 budget included a proposal “modeled closely after the Graham-Cassidy-Heller-Johnson (GCHJ) bill.” It would repeal federal financing for the ACA’s Medicaid expansion and health insurance marketplaces, using most of the savings for a state block grant for health care services. It would also impose a federal per-enrollee spending cap on the traditional Medicaid program. States could waive the ACA’s insurance reforms. The congressional bill also would repeal the employer shared responsibility provision (i.e., the employer mandate) and significantly expand tax breaks for health savings accounts, among other policies. The framework for this proposal — repealing parts of the ACA, replacing them with state block grants, reducing regulation, and expanding tax breaks — is similar to the 2016 Republican platform.

One policy initiative in the recent Republican platforms but not embraced by the president is Medicare reform. The idea of converting Medicare’s defined benefit into a defined contribution program and raising the eligibility age to 67 was supported by Vice President Mike Pence when he was a member of Congress and by Speaker of the House Paul Ryan.

Likely Democratic Campaign Plan: Improve the ACA and Add a Public Plan

It is possible and maybe probable that the ultimate Democratic Party platform in 2020 will resemble that of 2016: build on the ACA and include some sort of public plan option.

The Democrats will inevitably discuss a public plan in their platform, although the primary contenders will most likely disagree on its scale (e.g., eligibility) and design (e.g., payment rates, benefits). In September 2017, Senator Bernie Sanders introduced the Medicare for All Act (S. 1804). It would largely replace private insurance and Medicaid with a Medicare-like program with generous benefits and taxpayer financing. “Medicare for more” proposals have also been introduced: Medicare Part E (Merkley, S. 2708), an option for individuals and small and large businesses; Medicare X (Bennet, S. 1970), which is available starting in areas with little insurance competition or provider shortages; and a Medicare buy-in option, for people ages 50 to 65 (Higgins, H.R. 3748). A Medicaid option (Schatz, S. 2001), similar to Medicare Part E, offers a public plan choice to all privately insured people, aiming to capitalize on the recent popularity of that program. Publicly sponsored insurance plans have long been included in Democratic presidents’ platforms, although the government’s role has ranged from regulating the private plans (Carter, Clinton) to sponsoring them (Truman, Obama). It may be that the candidate who prevails in the primaries will determine whether the Democratic platform becomes “Medicare for all” or “Medicare for more.”

From the Discussion

The direction and details of the campaign plans for 2020 will be developed in the coming months and year. Given such plans’ potential to shape the next president’s agenda, now is the time to scrutinize, modify, and generate proposals for health reform.…


Alexandria Ocasio-Cortez Defeats Joseph Crowley in Major Democratic House Upset

By Shane Goldmacher and Jonathan Martin
The New York Times, June 26, 2018

Representative Joseph Crowley of New York, once seen as a possible successor to Nancy Pelosi as Democratic leader of the House, suffered a shocking primary defeat on Tuesday, the most significant loss for a Democratic incumbent in more than a decade, and one that will reverberate across the party and the country.

Mr. Crowley was defeated by a 28-year-old political newcomer, Alexandria Ocasio-Cortez, a former organizer for Bernie Sanders’s presidential campaign, who had declared it was time for generational, racial and ideological change.

Mr. Crowley’s loss left Democrats in Washington stunned.…

The debate over health care will likely play a significant role in the 2020 presidential election. Jeanne Lambrew has considerable political experience in health reform, having worked for President Obama as deputy assistant for health policy. She has studied health care reform proposals in prior presidential elections. What does she predict for 2020?

Lambrew predicts that the Republicans will propose replacement of the Affordable Care Act with devolution and deregulation. She predicts that the Democrats will support improving the Affordable Care Act and propose adding a public plan, presumably a public option or perhaps a Medicare buy-in.

Yet public support for a single payer Medicare for all program is at an all time high. It may have played a role in the impressive victory of Alexandria Ocasio-Cortez over stalwart Democratic leader Representative Joseph Crowley in yesterday’s New York congressional Democratic primary. Ocasio-Cortez was an organizer for Bernie Sanders’s presidential campaign and supports progressive policies, including Medicare for all. Crowley is a cosponsor of the Medicare for All Act but is also “an outspoken supporter of Obamacare” according to his campaign website – a position inconsistent with advancing bona fide single payer legislation. The fact that Democrats in Washington were stunned by his defeat may awaken them to the fact that the voters really do want an improved Medicare for all.

Lambrew writes, “now is the time to scrutinize, modify, and generate proposals for health reform.” Actually it’s late for that, rather now is the time to show the politicians how strong the support is for Medicare for all. After the presidential campaign begins, the political parties will have already decided on their policy positions and it will be too late to change their strategies.

Don’t forget the Republicans. Medicare for All may be a welcome antidote for Trump fatigue.

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