The Democratic Dilemma: Health Reform 2020

Recent highly partisan arguments over the Affordable Care Act (ACA) launched healthcare reform to the forefront of American politics. Although the ACA is likely to remain intact because of the division of Congress in the 2019-2020 session, the future of health insurance after 2020 remains uncertain. The healthcare platforms of the 2020 presidential candidates will need to include strategies to allay exorbitant medical bills, ensure security for patients with preexisting conditions, and provide coverage for the uninsured.

Given historical precedent, the Democratic candidates’ platforms will likely supplement restoration of the ACA with inclusion of a type of public health insurance plan. Because current public plans exist on a spectrum, each with varying degrees of private elements, candidates will have options on how exactly to expand public programs. At the more conservative end, one option is to mandate that private plans incorporate public plan elements, such as extending the reach of regulated fee schedules. This may reduce out-of-pocket financial exposure and cost containment, but would also mandate government interference with private insurance. 

Alternatively, another option will be to support the integration of public plans alongside private plans, as separate insurance choices for individuals. Although this would help expand coverage, it may risk redistributing enrollment to the extent that private plans are largely crowded out of the system. At the most extreme end, a single public plan providing universal health care, such as Medicare for All, could be endorsed. This would guarantee coverage for all but by drastically increasing the federal budget. 

At this point it is difficult to predict which platforms the candidates will adopt because each candidate’s platform will be shaped by both their views on healthcare reform and the current political climate. All of these proposed plans inherently increase governmental involvement in healthcare and are thus likely to further divide voters. Ultimately, the interplay between estimated costs, coverage implications, stakeholders, congressional support, and feasibility will contribute to the development and popularity of each plan.

This Policy Prescriptions® review is written by Rohit Gupta as part of our collaboration with the Health Policy Journal Club at Baylor College of Medicine where he is a medical student.

Abstract

Democratic candidates for president in 2020 will likely include some type of public plan in their health care reform platforms. Existing public plans take many forms and often incorporate private elements, as do most proposals to extend such plans. We review the types of public plans in the current system. We describe and assess the range of proposals to extend these plans or elements of them to additional populations. We suggest questions that candidates could use to guide their decisions about the scope and content of their health policy proposals. Developmental work during campaigns will contribute to success in turning candidates’ promises into accomplishments.

PMID: 30444427

Glied, SA and Lambrew, JM. Health Affairs. 2018; 37 (12): 2084-2091.