By Sheryl Gay Stolberg and Robert Pear
March 18, 2019 - The New York Times
WASHINGTON — No issue animated the Democrats’ 2018 congressional campaigns like health care and the promises to expand access to insurance and to lower costs. But as House Democrats sit down to draft their vision of governance in the coming weeks, lawmakers find themselves badly divided on the issue that delivered their majority.
Centrists from swing districts, with the tacit support of Speaker Nancy Pelosi, favor incremental moves to shore up the Affordable Care Act and to lower the out-of-pocket costs of prescription drugs and medical care. They are pushing a variety of measures, such as shutting down cheap, short-term insurance plans that do not cover pre-existing medical conditions and allowing people to buy into Medicare at age 50 or 55.
“We have very practical solutions that we can implement immediately,” said Representative Kim Schrier, Democrat of Washington, who is also a pediatrician. “We don’t have the luxury of time right now to wait for a full overhaul of our health care system.”
But they are butting up against an aggressive and expanding group of more than 100 outspoken Democrats — as well as at least four of the party’s presidential candidates — who want to do just that, upend the whole system with a single government insurance plan for all Americans — the old concept of single payer, now called Medicare for all.
“I reject the idea that single payer is impossible,” said Representative Alexandria Ocasio-Cortez, Democrat of New York.
The fight will play out in the coming weeks as the new House majority assembles its first budget, a policy document that will not hold the force of law but will carry significant political weight, revealing Democrats’ intentions not only on health care but on taxation, climate change, Social Security and other hot-button issues as well. But more than any other subject, Democrats’ achievements or failures on health care may well define them as they try to defend their fragile majority next year.
“Health care was on the ballot,” Ms. Pelosi declared in November, “and health care won.”
The idea of Medicare for all is immensely contentious. It would greatly expand the federal role in health care. Critics say it would require a big increase in federal spending, and proponents have not said how they would pay for it. Some versions of Medicare for all could wipe out much of the health insurance industry and replace employer-sponsored health plans that now cover more than 155 million Americans. Supporters say the proposal would guarantee universal coverage and put health care on a budget, reducing what consumers and employers spend. But insurance companies, along with many hospitals and doctors, are waging a vigorous campaign against it, believing that it would reduce the payments they receive for providing care.
Ms. Pelosi cannot afford to put moderate freshmen in Trump-friendly districts on the spot by putting Medicare for all up to a vote.
“Most people receive health care from their employer,” said Representative Scott Peters, Democrat of California and a vice chairman for the New Democrat Coalition, a centrist group. “They do not want to replace it with an untested government system.”
But that view is being challenged from some surprising corners of the party. Representative Debbie Dingell, Democrat of Michigan and no one’s idea of an upstart firebrand, is now a champion of the Medicare for All Act. She said the government was already delivering health care to significant areas of the population — the elderly, the poor, service members, children and veterans.
“We’ve got Medicare, we’ve got Children’s Health Insurance, and now it’s time for everybody,” said Ms. Dingell, whose husband, John, and his father before him, pressed for universal health care when they served in Congress. Before her husband died last month, she said, he told her to “bring it over the finish line.”
The debate reflects how much the political climate around health care has changed since passage of the Affordable Care Act in 2010. Former President Barack Obama had promoted the idea of a public option — a government-run health program to compete with private insurance on a federally run insurance marketplace — but moderate Democrats balked, and it was not included in the final law.
Senator Bernie Sanders, independent of Vermont, almost single-handedly put the idea of Medicare for all on the agenda during his 2016 presidential campaign. Since then, the concept has become a kind of litmus test for liberals. Republicans’ dismissal of it as socialism has only emboldened the new wave of liberal freshman Democrats in the House.
Backers of Medicare for all say that, if framed correctly around saving health care costs, it can appeal to voters in more moderate districts.
“Progressives have done a very good job making the moral case for Medicare for all,” said Representative Ro Khanna, Democrat of California. “What we now need to do is make the economic case.”
But with Republicans in charge of the White House and the Senate, the centrists argue that Congress needs to start with more incremental initiatives that could be slipped into larger bills, such as restoring money to enroll people in health plans on the Affordable Care Act’s exchanges. Other bills have bipartisan support; a measure drafted by Senator Susan Collins, Republican of Maine, would create state-based reinsurance programs to help pay large health insurance claims, thus lowering premiums on the act’s exchanges.
“After years of damage done to the A.C.A. from past Republican Congresses and the administration, we must start by reversing the sabotage,” leaders of the New Democrat Coalition wrote in a letter to the chairmen of three House committees responsible for health legislation.
Ms. Pelosi has publicly stayed out of the fight, but with hearings on Medicare for all and other proposals scheduled in the coming weeks, that stance may not be sustainable. People close to her say she has serious reservations about the single-payer bill and believes the nation can achieve the goal of universal coverage at a more manageable cost by building on the framework of the Affordable Care Act, which she worked tirelessly to secure in 2010.
Polls show the idea of a government-sponsored plan is broadly popular; the Kaiser Family Foundation, which tracks attitudes on health care, reported in January that 56 percent of respondents were somewhat or strongly in favor of a plan such as Medicare for all, in which all Americans would get their health care from the government. Even more — roughly three-fourths — were somewhat or strongly in favor of allowing people to buy into various government health plans.
When respondents were asked what they wanted Congress to work on, they prioritized keeping protections for people with pre-existing medical conditions and lowering prescription drug costs ahead of enforcing Medicare for all. And the polls show support for Medicare for all falls off when people are asked or told about details of the plans, including possible tax increases to pay for it.
Even so, Adam Green, a founder of the Progressive Change Campaign Committee, a liberal advocacy group, said that support for Medicare for all had become “a mainstream position” among Democrats.
“I don’t think the split is as much between progressives and more conservative Democrats,” Mr. Green said. “I actually think the bigger split is between Democrats who just ran and had competitive races in 2018 and a bunch of old-timers who didn’t experience the dynamic of 2018 and are still operating in yesteryear, where Medicare for all was seen as more of a fringe position.”
Many Democrats focused their election campaigns around protecting people with pre-existing conditions, and they want to move quickly to votes on proposals to do that — in part to test Republicans who made similar pledges during their campaigns. The full House has yet to vote on legislation on pre-existing conditions, though in the first 10 days of the new Congress, it voted twice to intervene in a lawsuit that threatens to eliminate the Affordable Care Act’s protections for people with such conditions.
The three House committees with jurisdiction over health care — Energy and Commerce; Ways and Means; and Oversight and Reform — have channeled their energies into numerous hearings on how to lower prescription drug costs, how to expand coverage and protect people with pre-existing conditions and how to override actions by the Trump administration.
Legislation is coming. Democrats are considering restricting the sales of short-term insurance policies, approved by the Trump administration, that do not have to comply with the Affordable Care Act, which means they do not have to provide essential health benefits and can discriminate against those with pre-existing conditions. Democrats are also looking for ways to cooperate with Republicans on proposals to lower prescription drug prices and to outlaw tactics used by brand-name companies to delay competition from generics.
Hearings on Medicare for all will begin as early as April, according to Representative Pramila Jayapal, Democrat of Washington, who is leading the push for the Medicare for All Act.
Under the bill sponsored by Ms. Jayapal and Ms. Dingell, the secretary of health and human services would establish a “national health budget,” specifying the total amount to be spent each year, and a national fee schedule for health care providers. Republicans have recently been demanding hearings on it, in the belief that they can score political points by showing that the proposal would be immensely expensive and disruptive.
Ms. Dingell said she intended to travel the country to push for the proposal. For her, it is carrying on a family legacy. Her husband’s father, John Dingell Sr., introduced the first universal health care bill in 1943 when he served in Congress; when the younger John Dingell was elected in 1955, he took up the cause and presided 10 years later when Congress passed the law enacting Medicare. A self-described pragmatist, Ms. Dingell acknowledged that the current bill may be only the beginning of a longer conversation.
“Social Security didn’t pass overnight,” she said. “Medicare didn’t pass overnight.”