‘Medicare for all’, the constitutionality of Obamacare and how to deal with rising medical costs are the main healthcare issues that will be fought over in the lead-up to the 2020 election, writes Bette Browne
Afordable healthcare is now the top concern for most Americans and will be centre stage in the US Congress this year, with Republicans and Democrats battling to seize control of the issue and set the stage for the 2020 Presidential election.
For the first time in at least a decade, more Americans cite healthcare as their top concern, ahead of the economy or any other issue. Forty-one per cent of those polled by the NBC network cited healthcare as their top issue, while roughly 70 per cent of all voters, Democrats and Republicans, said the American healthcare system needs “major changes”.
The mid-term elections in November 2018 helped propel the Democrats to victory in the House of Representatives, with polls showing healthcare was the top concern for voters. But their agenda still faces strong opposition in the Republican-controlled Senate and in President Donald Trump’s White House.
Republicans have vowed to continue their assault on former President Barack Obama’s Affordable Care Act, popularly known as ‘Obamacare’, while Democrats have pledged to safeguard it and protect Americans with pre-existing health conditions.
Medicare for all?
The youngest member of the new Congress, 29-year-old New York Congresswoman Alexandria Ocasio-Cortez, stormed to victory on a platform that called for universal healthcare for Americans or ‘Medicare for all’, which would mean expanding the government-run insurance programme for those aged 65 years and over to cover all Americans.
All Democrats generally support universal coverage and universal access to healthcare. The differences within the party are about how to achieve this goal. But now, having seized control of the House of Representatives, members feel emboldened, particularly the newly-elected younger members, and are demanding the issue stay centre stage until it is resolved.
But the Democratic Leader of the House Nancy Pelosi and some other senior members of the party are holding back from fully embracing ‘Medicare for all’, conscious that it will mean higher taxes in the form of salary deductions. They are talking mainly about improving the Affordable Care Act, protecting cover for people with pre-existing conditions and lowering the cost of prescription drugs — and probably a more gradual expansion of Medicare. But others in the party see no reason why they can’t focus both on protecting Obamacare and pushing their ‘Medicare for all’ plan, even if it means more taxes.
‘Medicare for all’ would virtually abolish the private insurance companies, their high co-pays and high deductibles. Instead, the federal government would gather revenue, primarily from workers’ pay deductions, which would be earmarked for medical care and use this to pay doctors, hospitals, nurses, clinics and other providers.
Further support for extending Medicare to all Americans came in a 8 January Harvard/Politico poll showing that 71 per cent back a Medicare buy-in option for people aged under 65 years. Of these respondents, 83 per cent are Democrats and 60 per cent are Republicans.
A public health insurance option that would compete with private insurance companies was supported by 65 per cent of respondents — 70 per cent Democrats and 51 per cent Republicans. The poll also found that 91 per cent support protections for people with pre-existing conditions. Such protection was a central part of the 2010 Affordable Care Act, which has been under almost constant threat from Republicans.
In preparation for hearings on the issue, the chairman of the House Budget Committee, Congressman John Yarmuth, has asked the Congressional Budget Office to carry out an analysis of single-payer healthcare proposals.
“The House Budget Committee will soon schedule hearings to review potential ways to achieve affordable, high-quality healthcare coverage for everyone, including Medicare for all. To begin that work, I have requested that the Congressional Budget Office provide a report on the design considerations that policy-makers should consider in developing proposals to establish a single-payer system in the United States,” Yarmuth said in a statement.
Chastened by their failed attempt to repeal Obamacare and their losses in the congressional elections, Republicans seem increasingly aware that even their own supporters want them to spend less time trying to repeal Obamacare and focus instead on new solutions to health coverage.
“Healthcare is such a significant part of our economy and the challenges are growing so great with the retirement of the baby-boomers and the disruption brought about by Obamacare that you can’t just cede a critically important issue to the other side,” according to Republican strategist Mr Whit Ayres.
“Republicans need a positive vision about what should happen to lower costs, expand access and protect pre-existing conditions,” he added. “You’ve got to be able to answer the question: ‘So what do you think we should do about healthcare?’” Americans are answering the question by stressing that two approaches are essential —the reduction of drug costs and ensuring access to affordable health insurance that covers pre-existing conditions.
Rising costs
Spending on medical care in the US has skyrocketed in the past 20 years and is now hitting record levels, but without comprehensive health insurance, millions of Americans don’t have access to such care. The US spends 18.2 per cent of gross domestic product on healthcare. That amount has jumped more than 260 per cent since 1960, when the US spent 5 per cent of GDP on health costs. In the past decade alone, the percentage of costs to GDP has risen roughly 10 per cent, with Americans spending twice as much as any other high-income country in the world on medical care.
The skyrocketing cost of drugs is one of the main drivers of this high healthcare bill. An analysis on 23 January by the Health Care Cost Institute, which tracks insurance claims data on about 80 million people, showed the cost of insulin for treating type 1 diabetes nearly doubled over a five-year period. For the average patient using 60 units per day, the daily cost went from $7.80 in 2012, to $15 in 2016.
Democrats in Congress, seeking to control such costs, introduced legislation aimed at lowering prescription medicine costs for consumers and sent letters to 12 drug-makers seeking information on price hikes. But it’s not at all certain that they will have the political strength to prevail, given the financial clout of the pharmaceutical companies and their congressional lobbyists, who, according to the Centre for Responsive Politics, have spent over $350 billion over the past 20 years to ensure favourable policies. Last year saw $27 million contributed to congressional campaigns, which was almost evenly split among Democrats and Republicans. However, 72 per cent of candidates on the Democratic Congressional Campaign Committee list were said to have rejected corporate money, including funds from drug companies.
Still, it will be an uphill battle to get concrete action on controlling costs, although Speaker Pelosi has pledged that Democrats would take “very, very strong legislative action” to lower costs.
Obamacare ruled ‘unconstitutional’
Meanwhile, just days before the new Congress met in January, a Texas court ruling declared Obama’s Affordable Care Act unconstitutional, sending shockwaves around the country, where millions, especially poorer Americans, now depend on it to help pay for their health insurance.
In striking down the law, Judge Reed O’Connor sided with a group of 18 Republican state attorneys general and two Republican governors who brought the case and who were supported by the Trump administration. O’Connor said the tax Bill passed by Congress in December 2017 effectively rendered the entire health law unconstitutional. That tax measure eliminated the penalty for not having insurance.
The 16 Democratic state attorneys general who intervened in the case to defend Obamacare vowed to appeal the ruling. Democrat Xavier Becerra, Attorney General of California, said the ruling was “an assault on 133 million Americans with pre-existing conditions, on the 20 million Americans who rely on the ACA for healthcare, and on America’s faithful progress toward affordable healthcare for all Americans.
“The ACA has already survived more than 70 unsuccessful repeal attempts and withstood scrutiny in the Supreme Court,” Becerra said in a statement. “This misguided ruling will not deter us. Our coalition will continue to fight in court for the health and wellbeing of all Americans.”
It is all but certain the case will become the third time the Supreme Court decides a constitutional question related to the ACA. The court upheld the law in 2012, ruling that the individual mandate is considered a tax and that Congress has the authority to levy taxes. In 2015, the court upheld the law’s tax subsidies for low- and middle-income earners.
But the Texas ruling also served to galvanise Democrats to push even harder for ‘Medicare for all’. Congressman Jan Schakowsky of Illinois, a member of the party’s Medicare for all caucus group, said the fallout from the lawsuit “may help us move on an even more bold and aggressive agenda” on healthcare.
Most of the legal challenges to Obamacare have centred on questioning aspects of its constitutionality. However, Democratic Congressman Ro Khanna of California pointed out that the constitutionality of the Medicare programme, on the other hand, has been well established. “There’s no doubt that [Medicare for all] would be constitutional. Medicare is already constitutional and what we’re saying is, extend it to everyone so there can be no constitutional argument,” Khanna said after the Texas decision.
The Texas case could also have political consequences for Republicans in the 2020 Presidential race. If the current challenge lands in the Supreme Court, it would likely be right in the middle of election year preparations and would serve to remind voters of Republicans’ efforts to repeal Obamacare and its protections for people with pre-existing conditions.
2020 election
A number of Democrats have already either entered the 2020 White House race or are preparing to do so and many of them are planning to make healthcare as central an issue in their campaigns as it was in the 2018 congressional elections.
California Senator Kamala Harris, who announced on January 21 that she was running for the Presidency, is seen as a strong candidate. As far back as 2017, she endorsed a ‘Medicare for all’ healthcare Bill by Senator Bernie Sanders, calling it “the right thing to do”. The Bill, which subsequently failed to pass in the then Republican-controlled Congress, was co-sponsored by another likely 2020 candidate, New Jersey Senator Cory Booker.
Massachusetts Senator Elizabeth Warren, who has also declared her candidacy, backs ‘Medicare for all’. “It [Medicare for all] is a way to give every single person in this country a guarantee of high-quality healthcare that is much easier to navigate and more affordable.”
Another Democrat likely to join the 2020 race is former Texas congressman Beto O’Rourke. He came close to defeating Republican Senator Ted Cruz in heavily-Republican Texas in the 2018 election, while running on a platform that included “achieving universal healthcare coverage,” which is similar to single-payer or ‘Medicare for all’.
A Reuters-Ipsos poll in the lead-up to the 2018 congressional elections found that 70 per cent of people support Medicare for all or a single-payer health system. Eighty-five per cent of Democrats supported the idea, compared to 52 per cent of Republicans.
But while Democrats captured the House majority in the mid-terms because of their message on healthcare, this has not deterred President Trump from moving ahead with his own health agenda, emboldened by the fact that the Senate is still controlled by Republicans and can thus block or derail the Democratic agenda.
The administration will also continue its efforts to weaken provisions of the Affordable Care Act, including taking aim at protections for pre-existing health conditions and opposing the expansion both of the Medicaid programme for low-income Americans and the Medicare programme for the elderly.
But, having lost the House of Representative and failed to crush Obamacare, it is possible as the 2020 election nears that President Trump may soften his stance against ‘Medicare for all’. It often gets forgotten, for example, that the President, according to Michael Wolf’s book Fire and Fury, once asked aides: “Why can’t Medicare simply cover everybody?” before eventually pushing for a repeal and replacement of Obamacare.
He will also be conscious of the fact that in the 2018 congressional elections, the expansion of the Medicaid programme was popular with voters in a number of Republican states. States like Idaho, Nebraska and Utah, for example, passed ballot initiatives to expand Medicaid, while voters in Kansas, Maine and Wisconsin elected governors who support Medicaid expansion.
Gender definition and other issues
Other aspects of his controversial health agenda include a push to limit or completely eliminate federal protections for transgender individuals. The administration wants to change the definition of gender under a federal civil rights law to either male or female, as defined by a person’s sex at birth. The policy change is being promoted by the Department of Health and Human Services, as well as other federal agencies.
The potential change has alarmed activists and medical professionals. The American Medical Association, the country’s largest physician lobbying group, said it will “oppose efforts to deny an individual’s right to determine their stated sex marker or gender identity”.
AMA board member William E Kobler said in a statement: “It is essential to acknowledge that an individual’s gender identity may not align with the sex assigned to them at birth. A narrow limit on the definition of sex would have public health consequences for the transgender population and individuals born with differences in sexual differentiation, also known as intersex traits.”
The administration is also pushing plans that would make it more difficult for abortion providers to receive federal family planning money. The Department of Health and Human Services will also continue to allow states to impose work requirements on those receiving Medicaid. So far, they have approved work requirements in five states and several more states are expected to get similar approvals.
Critics say the Trump administration’s aim is to remove people from the programme and thus save money for states. The record tends to support this contention because over 12,000 people in Arkansas lost health coverage after it became the first state to implement the work requirement.
The administration is also moving to change safety rules for nursing homes, suggesting that by removing “regulatory burdens”, the move will save money for nursing home providers. Democrats counter that the new rules will put the lives of elderly people at risk.
Meanwhile, the President’s health agenda suffered a setback in January when a Pennsylvania judge blocked the administration from enforcing new rules allowing employers to opt out of implementing an Obamacare provision on free birth control coverage for employees. The ruling came just a day after a California judge made a similar ruling.
While the focus of Democrats in the new Congress will continue to be on ‘Medicare for all’, the issue of gun violence, which has reached epidemic proportions in America, has also become part of the debate. As well as championing ‘Medicare for all’, Alexandria Ocasio-Cortez, for example, also pledged to work for a ban on assault weapons.
The issue of gun control has always been controversial in America, where over 100 people are killed by firearms each day. During the congressional elections, doctors became central to the debate after the powerful pro-gun group the National Rifle Association (NRA) said that, instead of speaking out on the issue, doctors should “stay in their lane”.
The NRA tweet that declared “someone should tell self-important anti-gun doctors to stay in their lane” came after the American College of Physicians (ACP) issued a major paper about gun violence prevention.
“Firearm violence continues to be a public health crisis in the United States that requires the nation’s immediate attention. The ACP is concerned about not only the alarming number of mass shootings in the United States, but also the daily toll of firearm violence in neighbourhoods, homes, workplaces and public and private places across the country,” the ACP said, urging doctors to speak out on the issue.
In the weeks that followed, photos of emergency department staff holding #ThisIsOurLane signs flooded Twitter, accompanied by medical research about gun violence. Some tweets from doctors also included pictures of blood-spattered scenes in emergency theatres after treating incidents of gun violence.
Dr Esther Choo, an emergency doctor and associate professor at the Oregon Health and Science University, tweeted: “We are not anti-gun: We are anti-bullet holes in our patients.” Dr Tomas Diaz, an emergency physician at the University of California, San Francisco, wrote: “Gun violence is very much our lane. And advocating for those who have lost their lives and loved ones is our duty.”
Another doctor, Dr Jennifer Gunter, tweeted: “Who do you think removes bullets from spines and repairs (or tries to) livers blasted by an AR-15? The tooth fairy? This literally is medicine’s lane.”
The American Foundation for Firearm Injury Reduction in Medicine (AFFIRM) also sent a hard-hitting letter to the NRA, titled ‘This is our lane: An open letter to the NRA from American healthcare professionals’. It said in part: “Every medical professional practising in the United States has seen enough gun violence first-hand to deeply understand the toll that this public health epidemic is taking on our children, families, and entire communities. It is long past time for us to acknowledge the epidemic is real, devastating, and has root causes that can be addressed to assuage the damage.”
The letter ended by urging Congress to stand up to the NRA’s lobbying efforts against gun-control measures. “Our research efforts have been curtailed by your (NRA) lobbying efforts to Congress. We ask that you join forces with us to find solutions… We are not anti-gun. We are anti-bullet hole. Join us, or move over! This is our lane.” The episode was an unprecedented intervention on social media by US doctors and could help to boost gun control efforts in Congress.
But, tough and all as the gun control issue is in America, the ‘Medicare for all’ campaign is going to be far tougher, especially as it becomes enmeshed in the volatile politics of the 2020 Presidential race.
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