WASHINGTON—Outnumbered but emboldened, progressive Democrats who watched Republicans fail to unwind the Affordable Care Act are thinking harder about passing major expansions of health-care coverage. For many younger activists and legislators, the push to undo the ACA with just 51 Senate votes is less a cautionary tale than a model of how to bring about universal coverage.
The ambitious idea, discussed on the congressional backbenches and among activists, is not embraced by Democratic leaders. In the hours after the repeal push stalled, Senate Minority Leader Charles E. Schumer suggested that Republicans “sit down and trade ideas” with Democrats. House Minority Leader Nancy Pelosi suggested that Republicans fully fund subsidies for current ACA exchange plans — money that U.S. President Donald Trump frequently threatens to cut off.
But for many younger Democrats and activists, the Republicans’ near-miss on repeal demonstrated boldness from which a future left-wing majority could learn. Democrats passed the ACA through regular order, with a fleeting, fractious Senate supermajority. Republicans proved that major health-care policy changes can be pushed nearly to the finish line in the reconciliation process, with just 50 supportive senators and a vice-president ready to break a tie.
Rep. Ro Khanna, a freshman California Democrat who favours universal Medicare coverage, said that Republicans have rewritten the playbook. “When we do have a Democratic president, and when we do have a Democratic majority, I’d support getting this through with 51 votes in the Senate,” said Khanna of a universal coverage, single-payer plan.” That will diminish the role of lobbyists and special interests in trying to get a few senators to block something that everyone in this country will want.”
Democrats who endured previous efforts to expand health insurance had rarely considered a reconciliation strategy. In 2009, the Obama administration and Democrats in the House and Senate included veterans of the failed 1993-1994 health-care push, who remembered the insurance industry’s effectiveness in sinking their bills.
The 2009 approach brought insurers on board; it adopted the mandate for individuals to obtain health insurance, an idea cooked up in conservative policy circles, and went into affect slowly to avoid piling up costs.
“How much time and effort did they spend in trying to make the ACA bipartisan?” asked Rep. Ruben Gallego, a rising Democratic star elected in 2014. “It’s never going to happen. Our bills shouldn’t be about getting the most amount of Republicans on board; they should be about insuring the biggest number of people.”
When Democrats lost control of the House in 2010, it taught party activists that there was little to gain from compromise. This year, the ACA policy that proved most intractable was not the mandate — a “skinny bill” to repeal it got 49 Senate votes — but instead the expansion of Medicaid, which up to nine Republican senators refused to roll back.
To progressives, this was proof that they’d been right to demand more in 2009 — from a public option to a Medicare buy-in for younger people to single-payer health care itself. Adam Green, the co-founder of the Progressive Change Campaign Committee (PCCC), recalled that Democrats had ridiculed the “professional left” for supporting a public option in reconciliation. In conversations since the start of the repeal debate, they’ve come to agree with him.
“In 2009, what we consistently got from Democratic senators was: Hey, reconciliation was a procedural can of worms. We don’t want to go there,” said Green. “Republicans have made very clear that you can go there and push your ideas into law. But our ideas will be more popular. It’s pretty clear that the centre of gravity has shifted.”
Last week, as the Senate debated then waylaid the repeal bills, the PCCC held all-day training sessions for 2018 Democratic candidates in a hotel near the Capitol. Many swing-district hopefuls either said they embraced single-payer health care or described it as an obvious goal to work toward.
“The image I have in my head is that everyone who wants to see a doctor can see one, without going to the ER or going bankrupt,” said Rick Neal, an international aid worker who was exploring a run against Rep. Steve Stivers, an Ohio Republican. “Health care doesn’t fit in this free-market fantasy that people have, because people will do anything to see a doctor. The high premiums we’re seeing right now are an indication of market failure.”
Andy Kim, a former National Security Council staffer now running against Rep. Tom MacArthur, Republican of New Jersey, described the ideal process for passing a bill in now-common progressive terms — starting with what voters want, not what might win over Republicans.
“The way you start something that’s bipartisan is by starting with the American people,” he said. “Bipartisanship starts with them.”
Democrats have not yet formed a consensus on how to approach health care again. On Thursday, as the repeal effort headed for the cliff, Sen. Steve Daines, Republican of Montana, needled Democratic senators — 10 of whom face re-election next year in states Trump won — by introducing the text of a single-payer bill sponsored by Rep. John Conyers Jr., Democrat of Michigan. For the first time, most House Democrats have co-sponsored Conyers’ bill; 43 members of the Senate minority, including Sen. Bernie Sanders, voted “present,” while five voted “no” on the Daines amendment.
Sanders did so because he intends — barring yet another jolt of life in the repeal campaign — to release a “Medicare for All” bill before the Senate’s August recess. The bill will be designed to reframe single-payer, which enjoys tentative support in public polls, as cost-effective and sensible.
If Sanders’ bill gets a favourable CBO score, it would become a starting point for Democrats in future health-care debates. Even some progressive Democrats worry about the story getting ahead of the storytellers.
“The reconciliation rules may allow you to squeeze through something, but it doesn’t allow you to do law-making the way it’s supposed to be done,” said Sen. Brian Schatz, Democrat of Hawaii. “When it comes to repeal, reconciliation is the tool that they’ve used; there’s every reason to think we’d use reconciliation to undo it. But it’s not a path we should go down with enthusiasm.”
Rep. John Yarmuth, Democrat of Kentucky, who would chair the House Budget Committee if Democrats won control of Congress, was similarly cautious about reconciliation. In an interview with the Washington Post and the New York Times, Yarmuth said that he supports universal Medicare and could see it becoming law “in five to 10 years,” as employers realized that they would gain flexibility if they were taxed slightly higher but could save on insurance costs. But he would not copy the process Republicans had tried to use for repeal.
“It’s not good for the country, whether you’re Democrat or Republican, when you pass a bill with only partisan votes,” said Yarmuth.
Conyers, meanwhile, was trying to make universal health insurance the party’s default position. On Friday, as most House members left town for their recess, Conyers joined Khanna at an event to launch a pledge for 2018 Democrats. Raising his right hand, the Capitol peering over his shoulder, Conyers said he would “stand up for ‘Medicare for All.’ ”
“We’re seeing a crumbling of the Republican legislative program,” said Conyers. “We may not be in the minority much longer.”