GeminiD in yesterday’s post asked a good question:
I’m curious, though: if the Democrats have a trifecta after 2024, what additional healthcare reforms do you think they should pursue?
Really good question and coincidentally, I’m doing some homework on different strands of Democratic health reform thought for class this week, so I have some thoughts. I’m going to make a few assumptions. First, the president will be Joe Biden (or if not him, someone from his wing of the party), secondly, the Democratic Senate will not have Joe Manchin as a critical vote either because he retired/defeated in 2024 or the Democrats are working with 51-53 votes. Third, the fillibuster will be a barely binding constraint so we’re in 218-51-1-5 zone. Finally, I want to pull back to something I wrote in January 2019:
A very productive Senate might have slots for two big bills, three or four medium actions (such as SCOTUS nominees) and a lot of housekeeping. A productive Senate is most likely positively correlated with the size of the effective majority…
Candidates are likely to share the same items on a top-10 list but the rank ordering and asset allocation will matter a lot. One candidate might want to spend six months on healthcare again at the cost of doing not much if anything on immigration and naturalization. Another candidate could want to spend a little time on a minimal “fix-it” healthcare bill while spending more time on global warming policy. Those are all defensible choices.
From the 2022 perspective on 2021, the biggest of big things was ARPA which passed and BBB which is mostly dead and may be partially resureccted to storm the Senate castle under a different name and policy intent. In 2022, the big thing is likely to be foreign policy.
So the question is, how much time and effort is a moderate Democratic administration and a thin majority on the Hill willing to spend on healthcare? I think there is a bit.
I think there is an appetite to extend ARPA ACA subsidies.
I think there is an appetite to do something about drug pricing as in BBB.
I think there is an appetite to extend the no surprise billing law a bit broader (ambulances and labs).
I think there is an interest to sending a firehose of federal money at the Medicaid expansion hold-out states.
I think there is a willingess to encourage state initiated public options tied to ICHRAs to slowly chip away at one size fits few employer sponsored health insurance but that can mostly be done administratively.
I think there is interest to engage on administrative burden reduction for Medicaid.
I think there is interest to allow/encourage/fund the Federal Trade Commission to do more against mergers. (I’m shaky on this one)/
I don’t think there are 51 votes in any plausible Senate for Medicare for All.
Now if my core assumptions are wrong, then who the hell knows, but realistically, I think that from the Democratic point of view, there are a lot of fixes and tweaks they want to do but very little appetite to spend a year on health care reform in 2025.
rikyrah
I think that the dental ,vision , and hearing will be covered in Medicare..
Manchin has been against it.
I think the Medicare age will be lowered too
We make Manchin and Sinema irrelevant..we will get the BBB.
lowtechcyclist
Since the absolute best thing we can do to disempower Russia (and other petro-states) is to dramatically reduce our dependence on fossil fuels, I’m hoping that the climate change parts of BBB get resurrected as a defense measure. Hell, put DoD in charge of implementation, and put the whole thing into the next defense budget bill.
lowtechcyclist
@rikyrah: If I had to choose between adding dental/vision/hearing to Medicare, or lowering eligibility to 55 or even 60, I’d go for lowering the eligibility age.
Because once you lower it, there’s no reason not to lower it again in a few years – and each lowering is cheaper than the last, since younger people are cheaper to cover than older people. And that’s probably the easiest route to universal health coverage.
Kay
I hope not. I enthusiastically support Medicaid in states that support it but Democrats need health policy that also gains them votes and political power. If people in these states want Medicaid expansion they can start voting for it.
Democrats have a free rider problem. Tens of millions of people don’t vote for us, will never vote for us, because they’re completely confident we’ll protect and expand the programs they rely on no matter what happens.
Baud
Something that I would like to see happen that won’t is a weakening of ERISA preemption so blue states can do more.
Baud
@Kay: Agree. We’ve done what we need to do.
rikyrah
@Kay:
I agree.
Help those who helped themselves
Nettoyeur
First the Dems need to win. A bloody uphill fight against a GOP who will commit high treason to get into power. Writing Good Gov drivel like this is an excellent start to a losing campaign.
Kay
Obama extended access to health care to tens of millions of lower income white people in purple and red states at great political cost and for that Democrats were rewarded with Donald Trump and Right wing culture war attacks that directly harm our actual base, our people, supported by the same people who benefitted from government health care programs.
Choose something that is good policy but also appeals to, benefits, and grows our base.
Geminid
“Medicare for All” appeals to me in principle. But as a means to an end, Medicare for All may not be so superior to a blended system of public programs and private insurance, which seems to be our present path.
I do have strong reservations about M4A’s as a political program. It was hard enough for Joe Biden to win when he ran against Trump and the fascist Republican party. I don’t think he could have pulled it off if he was running against a large portion of the medical industry as well.
p.a.
My idiot cousin watched a black mole spread across his torso because he had no medical: malignant melanoma. Signed up for Obamacare, got fixed. Still considers Obama & Dems Anti-Christs, votes straight R.
p.a.
Whatever improvements to gvt healthcare there may be, there are Fed Society moles throughout the judiciary to fast-track spurious lawsuits to the Supremos and CURRENTLY 5-6 justices who will invent any legal-ish reasoning out of straw & manure to block it.
Kay
@p.a.:
Trump and the far Right SCOTUS changed my view. They want to call us all pedophiles, pass ‘don’t say gay’ laws, treat pregnant women like the property of religious fundamentalists, gut voting rights? Okay. They can go back to the old red state health care system, which was going to the emergency room and then having your paycheck garnished to pay for it.
No reason Democrats should expend a dime of political investment on this. It’s time to take care of our actual base.
Fake Irishman
@Kay:
Medicaid expansion is remarkably popular and several academic studies have suggested that it does help Democratic vote share even among rural whites. And while a lot of rural white folks are helped, it also helps a lot of African American and poor Hispanic folks, and they would be major beneficiaries if places like Mississippi would expand. I believe those AA folks are about as much of a loyal Democratic constituency as there is in this country.
finally, you can pay for expansion or a federal expansion alternative for holdout states by taking apart Disproportionate Service Hospital funds, which are supposed to be used to cover care for uninsured folks, but have turned into massive slush funds for non- expansion states. Expansion helps people in our base, helps broader society and takes money away from selfish elites who are our political opponents as well.
I know this is frustrating seeing things from a rural white Ohio county (I’ve seen a lot of those as well) but from a major Texas city, things look a lot different.
Ohio Mom
Obviously I’m for anything that inches us closer to universal coverage. But as someone soon marking my two year anniversary of joining Medicare, meh on Medicare. Let’s have Medicaid for all, I like Ohio Son’s Medicaid way better than any medical plan I’ve ever had. Everything has been covered for him without a single issue.
Which reminds me, I have to make calls today to start unraveling my first Medicare billing snafu.
Yutsano
@p.a.: @Geminid
So, basically, Australia. Which has one of the best health systems in the world, so I am totally good with this.
Kay
@Fake Irishman:
I’d have to see those studies. The rural white vote share in my county has declined every year since 2008. If “cultural issues” are more important to them then basic health care for them and their families then I’m respecting their choice on that, but they shouldn’t have it both ways. They should get the whole conservative package. It comes without health care.
ProfDamatu
I’d also hope for expansion of cost-sharing reduction subsidies for Marketplace plans. The expansion of the premium subsidies is/will be an essential thing to do, but at this point, ACA plans are closer and closer to becoming unusable for many subsidized buyers who are too “rich” for CSR subsidies.
Yes, I do fully understand that someone making only 250% of FPL needs those subsidies more than someone making 350% FPL, but…that person making $40k can’t really afford $4600 in deductibles every single year that they need medical care (not a made up example – outside of two Gold plans with notably higher premiums, that was the *minimum* deductible available in my area; also, the lowest possible OOP max is $6500, with most being the statutory max). Possibly I’m just in a super shitty market area, and there are better plans available most places, but…I wonder.
Anonymous At Work
I don’t see an appetite for doing anything about mergers in the healthcare field, much less generally. This is a topic where SPW and Bernie could drag the caucus into action through grassroots pressure and peer pressure, rather than even a majority of the caucus wanting to do anything. To fight healthcare, hospital, insurance, etc. concentration would threaten the monopolies and oligarchies in each state. Sad but true.
Matt
The key issue will be expanding funding for treating horseback-riding injuries, because in that case everyone will obviously have a pony.