Despite seven years of demagoguery about the law’s effects, Republicans were unable to kill the Affordable Care Act. That’s given reformers on the left renewed confidence. The question of how best to keep the ACA’s unfulfilled promises will be a central issue in the 2020 election, and if Democrats regain power, the fight to further expand coverage and reduce health-care costs will likely be front and center.
Senator Bernie Sanders and Representative John Conyers have captured the energy of the progressive movement with similar proposals to make Medicare benefits significantly more generous than they are now—covering almost every medical expense, while eliminating co-pays and almost all other out-of-pocket costs—and then move almost the entire population into this more expansive program. Conyers would achieve this in one fell swoop, in under two years; Sanders would phase it in over four years.
But, as I wrote in August, these bills represent the most disruptive and difficult possible route to a comprehensive national health-care system. They’re too easy to misrepresent. Like any other deep reforms, they’d face concerted opposition from the right, centrist Democrats and health-care providers. But they’d face another obstacle, too: Because they compel so many people to give up their existing coverage for the promise of something better—all within a short period of time—they’re almost guaranteed to spark a popular backlash. Without strong popular support, these approaches are doomed to fail.
At the same time, Democratic lawmakers, think-tankers, and academics have offered a menu of incremental reforms that range from creating a public insurance program that would compete with private insurers in Obamacare’s exchanges to allowing people aged 55–64 to buy into Medicare to giving states the option of allowing anyone who lacks insurance to purchase coverage from their Medicaid programs. All of these ideas would bring about progress. And because they avoid a full-frontal assault on industry stakeholders, and leave the familiar employer-based insurance system in place, they’re more feasible politically. But they wouldn’t get us to universal coverage, and aren’t designed to aggressively control costs. More importantly, they’re unlikely to capture the imagination of young voters or energize the activist left. So the very practicality of these approaches is a major liability.
What we lack, and what we need, is a pathway to something like Medicare for All—or what Yale political scientist Jacob Hacker calls “Medicare for Most”—a scheme that establishes comprehensive health care as a right and is aggressive in challenging a status quo that continues to fail millions of Americans—but which would be merely very difficult to pass, rather than all but impossible.