Photographer: Andrew Harrer/Bloomberg

Medicare for All Tough Pill for Many House Democrats to Swallow

November 27, 2018 Shira Stein
  • Single payer resonated with base, not in competitive districts
  • Moderates’ pushback may spur search for options to fix system

Newly elected House Democrats who ran on a single-payer health insurance platform will find their campaign promise easier to make than to keep.

While the “Medicare for All” battle cry caught fire with progressive voters in safely Democratic districts, only 3 percent of Democrats who ousted Republicans in competitive districts supported universal, single-payer health care.

Champions of Medicare for All also will face opposition or uncertainty in their own caucus, wariness by House leaders, and a lack of seniority and clout to push for votes or committee hearings.

A single-payer health system “just didn’t resonate, except in very liberal districts where Medicare for All is a litmus test for knowing you’re a progressive,” Robert Blendon, a health policy professor at the Harvard T.H. Chan School of Public Health, said in an interview.

Twenty-two of the 40 Democratic members of the two House committees with jurisdiction over health care are cosponsors of the main Medicare for All bill in the House (H.R. 676), which would create a single-payer system. The top two members of Democratic House leadership, Nancy Pelosi (Calif.) and Steny Hoyer (Md.), haven’t expressed support for the measure.

And any health-care legislation would also need to pass in the Senate, where Republicans retained control. Republicans and President Donald Trump have consistently sought to repeal or undermine the Affordable Care Act, and pushing a House vote on single-payer would confront moderate House Democrats with a vote on legislation that is controversial at home and unlikely to become law.

‘It Takes Time’

Legislation to create a Medicare public option could offer Democrats a step forward. Twenty-eight percent of Democratic candidates who supported a public option won those competitive races, according to a Bloomberg Government analysis of Democrats’ positions on health care during the midterm elections.

“Policy is iterative, it takes time, and so I think it’s important for the House to push forward, and the Democratic majority, and ultimately get a Medicare for All bill passed,” Rep.-elect Joe Neguse (D-Colo.) said in an interview. “It may take us a couple of years, but ultimately, that’s the only way that we’re going to get the kind of progress that I think we’re going to need to make to get a universal health-care system in our country.”

The problem for moderate Democrats, Blendon said, is that a public option doesn’t get the blood boiling for the base. Propping up the Affordable Care Act, he said, may not be a winning issue for the 2020 primaries.

Fixing Obamacare

The biggest obstacle to Medicare for All is that the House flipped because Democratic candidates ran on promises to protect coverage for preexisting conditions and fix the Affordable Care Act, David Kendall, a senior fellow for health and fiscal policy at the centrist think tank Third Way, said in an interview.

Those priorities—along with reducing drug prices and overall health-care costs—will leave the new House majority with little time for hearings on an issue such as Medicare for All, which most Republicans ran against, Kendall said.

“The challenge really is trying to see where everyone is at, we’re just getting the first opportunities to have a conversation with our new colleagues,” Rep.-elect Ilhan Omar (D-Minn.) said in an interview. “It’s about having the opportunity to really discuss it, and we haven’t had that yet.”

Medicare for All is a terrific voting issue until you get into the discussion of taxes that the program would require, Blendon said. Candidates don’t have to answer how to pay for it, he added, and House leaders won’t want to be on the record with adding more taxes.

Although estimates of the cost of a single-payer system vary, the libertarian Mercatus Center and the liberal-leaning Urban Institute put the cost of Sen. Bernie Sanders’ (I-Vt.) plan at about $32 trillion over the first 10 years.

Moderate Democrats Wary

Some Democrats worry that a vote on Medicare for All could hurt them in their more moderate districts.

The makeup of Congress will require the majority to “focus on stabilizing the Affordable Care Act rather than come up with a totally new system” like Medicare for All, “which probably won’t have the votes,” Rep. Frank Pallone (D-N.J.), who is in line to be Energy and Commerce Committee chairman, told reporters.

Rep.-elect Deb Haaland (D-N.M.) isn’t worried that moderate Democrats will be an obstacle to Medicare for All. “I think we’re all going to stick together,” she said.

“We’re a big tent party, so I think folks have a variety of different ideas around the best way to provide universal care,” Neguse said. “We’re going to have a lot of conversations within the caucus about the best way to do that.”

Moderate Democrats need to do their job and pass Medicare for All without worrying that the vote could cost them reelection, said Kara Eastman, a congressional candidate in Nebraska who backed single-payer health care and lost her race.

Andrew Harrer/Bloomberg
Incoming House Energy and Commerce Chairman Frank Pallone (D-N.J.) favors fixing Obamacare before taking on Medicare for All.

Confusion About Details

Once lawmakers begin delving into the details of Medicare for All, they will have to settle on a common definition, Joel Ario, managing director of Manatt Health, said in an interview.

Just looking at a single-payer model will require them to decide whether they mean traditional Medicare, which doesn’t cover everything, or Medicare Advantage, which is run by insurance companies, Ario said. Supporters of Medicare for All sometimes talk about getting rid of insurance companies, but Medicare Advantage is seen as the better model, he added.

Areas for Compromise

The new members of Congress who support Medicare for All are already thinking about other areas of health care where they can push more progressive policies.

Democrats could also work to address the lack of competition in the individual market, and “there are a number of iterative steps that we could take to shore up the individual exchange,” Neguse said.

They might also promote more state innovation, such as the Health and Human Services Department allowing a Medicaid public option in some states, Ario said. They could “put pressure on HHS to be more flexible” and let states experiment with a public option while they’re working on the national version of Medicare for All.

Kendall said it would be a leap of faith for voters in purple districts to trust that Washington will take care of them. Congress would be better off, he said, fixing Obamacare first, to prove it can deliver and diminish suspicions around single-payer health care.

To contact the reporter on this story: Shira Stein in Washington at sstein@bloomberglaw.com

To contact the editors responsible for this story: Paul Hendrie at phendrie@bgov.com; Robin Meszoly at rmeszoly@bgov.com

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