The Long, Hard Road to Universal Health Care

Democrats have a long and distinguished history of fighting for universal health care (UHC).  In fact, it’s a century long history in which they’ve made some strides (Medicare, Medicaid, and Obamacare), but have also had a lot of setbacks – it has literally taken them 100 years to get these three pieces of legislation passed. 

To be absolutely clear, universal health care is a Democratic ‘thing’; Republicans want nothing of it and will do everything in their power to thwart accomplishing that goal.  And they have a lot in their favor, including control of the Senate, the presidency, and the Supreme Court.  They have a massive donor base, including the private health insurance industry to support their efforts.  Republicans have a powerful propaganda machine in Fox News, which now has more viewers than CNN, MSNBC, and PBS news.  And they also have a long history of obstruction and resistance, including voting against every piece of health care legislation Democrats have proposed over the past century.  They are the party that voted against Medicare and still want to privatize it, which would force millions of seniors into high deductible, high cost private insurance plans.  From a progressive point of view, rather than wearing American flag pins, Republicans should just wear badges labelled “dastardly villain.”

Republicans are better organized to resist universal health care legislation than Democrats are in promoting it.  For example, Republicans are supported in their efforts by a number of conservative think tanks and organizations, such as the Heritage Foundation, American Enterprise Institute, American Conservative Union, and the CATO Institute.  Moreover, the Republican Party is better at strategizing and coordinating the efforts of their conservative partners and as a result tend to do a much better job of communicating their position compared to Democrats. 

In regard to communication, Republicans are also better at framing.  For example, Republicans feel no hinderance in using disinformation and falsehoods to create doubt and mislead voters.  This is why, despite the fact that scientists are absolutely sure, based on a preponderance of evidence, that climate change is real and caused by human activity, Republicans are still able to convince a third of Americans that climate change is a hoax.  Similarly, the above organizations and others will provide the talking points Republicans will use to try to kill UHC legislation, including the well-worn catch phrases socialism, socialized medicine, and free health care.  Had Democrats promoted Obamacare after it was passed, they might have won the communications war.  Instead, they scurried away from it, and Republican used their silence to convince many voters that the ACA should be repealed and replaced. 

Bernie Sanders’ single-payer Medicare-for-All will replace the private health insurance industry, so, obviously, the health insurance industry will oppose his plan and will fund the opposition including hefty donations to Republicans.  What most Democratic supporters fail to understand is that Biden’s expansion of Obamacare by creating a public option is no less onerous to health insurers, because it is essentially an incremental approach to UHC.  With its lower costs for premiums and subsidies to reduce out-of-pocket expenses, the Biden plan will, over a number of years, siphon individuals and businesses away from the private market into the public option.  In other words, although it is touted as a way of enhancing competition to bring down costs, it’s really a road to UHC.  And the private insurance industry understands that.  Consequently, their opposition to the Biden plan will be no less fierce than their opposition to Sanders’ plan.

Sanders is counting on a people’s revolution to demand change.  If elected he will call on all Americans, Democrat and Republican, to put pressure on Congress to pass his Medicare-for-All plan, because it will be in their benefit.  He believes that the American people can be more persuasive and effective than the private health insurance industry’s lobbyists and money and that the facts will outweigh the disinformation Fox News will bring to bear.  That remains to be seen.

Biden is counting on having a Democratic majority in Congress who won’t be afraid of “fixing” Obamacare, which, despite Republican misinformation, is liked by the majority of Americans.  Biden believes he can take an incremental approach to fix specific problems over time, such as legislation to give Medicare the authority to negotiate drug prices, another bill to increase taxes on the rich to offset the increased cost of subsidies, a separate bill to create a public option, and so on.  And by giving private health insurers something in return, such as their being able to take advantage of negotiated drug prices, Biden hopes they’ll be less oppositional to other changes, such as creation of a public option.[1]  That too remains to be seen.

There are a number of factors in the political environment that are encouraging, although it is unclear whether they will be enough to help either candidate achieve their goals.  First, the majority of Americans, as reflected by opinion polls, are satisfied with their health care but not their health care insurance, as premiums continue to rise along with out-of-pocket expenses.  Their employers are equally dissatisfied with the rising cost of premiums and if a pubic option was available, employers would probably shift health coverage to that plan.  Thus the private business sector is more likely to favor change.  Additionally, the American Medical Association, long a foe of UHC, is now on board; for example, an increasing number of physicians favor single-payer as it is much less costly to administer.

Jesus was a healer, consequently, many Christian denomination has taken an official position in support of UHC.  Unfortunately, Christians are divided along political lines and as a result, conservative Christian churches and many of their congregates do not support universal coverage.  Despite Jesus’ teachings, they believe that individuals and not society are responsible for obtaining health care: if you can’t afford health care, well that’s not my problem, that’s not government’s problem, it’s your problem.  Obviously, many people of faith do understand the purpose of Jesus’ ministry and wholeheartedly support UHC, but it is important to recognize the faith community does not and will not support UHC as a cohesive segment of American society who can influence the political process.

Assuming that Biden or Sanders is elected president, but does not have a Democratic majority in both houses, can they affect change in health care policy?  Thanks to Donald Trump, the answer is yes.  Trump has accomplished very little working with Congress legislatively, however, he has had a significant impact through his executive orders.  Executive orders are often issued when a president wants a branch of government to operate more effectively or efficiently.  For example, under current law, Medicare is prohibited from negotiating drug prices, however, other government programs can, such as Medicaid and the Veterans Administration.  Theoretically, a president could order CMMS (the agency that administers Medicare) to base its rates on the rates Medicaid and the VA use to pay for medications.  Obviously, this would be contested in the courts, just as many of Trump’s executive orders have been challenged.  Nonetheless, a strong argument can be made that the executive order does not conflict with the law, as CMMS would not be directly involved in negotiating prices; instead, it’s just taking advantage of already negotiated prices to save consumers and the government money.

Health care reform is a major issue in the Democratic primaries and the Party wants to make it an issue in the general election.  However, in the end, it doesn’t matter which party wins the presidency.  Instead, a change in health care policy depends on whether Democrats can win majorities in both houses of Congress, particularly if they gain veto proof majorities.  If they do, then a Democratic Congress can pass whatever health care legislation they may choose and get it enacted even if a Republican president opposes it. 


[1] Biden may also believe he can “reach across the aisle” and work with his Republican colleagues as he did in the 1980s and 1990s.  That too is unlikely, as Republicans have no desire to work with Democrats.

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