If you had asked Democrats any time since the 2016 election what their highest policy goal for the Trump presidency was, most would have responded: Stop the Republicans from destroying the Affordable Care Act. It's Barack Obama's signature domestic achievement, there are literally lives at stake, and not inconsequentially, beating back a Republican effort to come through on a promise they've made for seven years would be both politically advantageous and deeply satisfying.
For now anyway, that victory is won. So where do Democrats go from here on health care?
While the Republican repeal bill was in play, there was one and only one goal: Beat back the threat it represented. But now that that threat has passed, Democrats need to begin an internal debate that will decide the next phase of reform.
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There were a lot of differences between what happened when Democrats set out to reform health care in 2009 and what happened when Republicans set out in 2017 to undo what Democrats had done. But so many of the problems Republicans faced grew out of the fact that they had never really had an internal debate about health care. Democrats had spent 15 years since Bill Clinton's failed reform effort figuring out what they'd do the next time they had the chance, and when the time came, they had settled on the basics, even if it wasn't perfectly satisfying to everyone. You may remember that in 2008, Obama, Hillary Clinton, and John Edwards all presented basically the same plan.
Republicans, on the other hand, all knew they hated ObamaCare and wanted it gone, but the "replace" part of "repeal and replace" hadn't been worked through. Most Republican members of Congress couldn't tell you much more than that they favored some kind of "patient-centered" plan, whatever that was supposed to mean. Their presidential nominee promised the public "something terrific," which is not exactly a concrete policy blueprint.
Then in a matter of a few weeks they had to come up with a plan, and what Speaker Paul Ryan put out couldn't get the unified support it needed to pass. Differences hadn't been resolved, compromises hadn't been considered, and for many a "no" vote seemed like the safest move to make.
Democrats don't want to find themselves in that position the next time they have the power to reform the system, so they need to start working now to arrive at the kind of plan they can all live with. Because whenever they do get that chance, Republicans will fight them, and they won't have much room for error.
So what should that plan be? If I were making the policy, we'd move toward something like the hybrid system they use in France, in which there's a basic public plan that covers everyone, then most people buy supplemental private insurance on top of that. It means virtually no one is uninsured (which would make liberals happy), and you're free to buy the fanciest insurance you want or can afford (which would make conservatives happy).
Getting from where we are now to a system like that would be complex and require a long period of transition. But we could do it piece by piece as we solve particular problems and bring insurance and security to more people. You could begin to get there by doing things like creating what Paul Starr calls "Midlife Medicare" for people between 50 and 64, and federalizing Medicaid, so Republican-run states would be less able to deny coverage to their poor citizens.
I can hear you saying: Republicans aren't going to like that! Of course not. But right now, Democrats are out of power. This is the time to start working through these ideas to fully understand their potentials and pitfalls. For instance, when Bernie Sanders was a presidential candidate, I thought his single-payer proposal didn't grapple with the political and policy obstacles it would face in the real world. Now he's introducing a new version, to which I say: That's great, let's talk about it.
Anything Democrats come up with has to do some important things. It has to address the problems that have arisen with the ACA, like the lack of multiple insurers in the individual market in some places, and the high out-of-pocket costs that people dislike so much. It also has to build on the ACA's success in insuring more Americans and beginning to restrain overall health spending. And it has to keep moving toward a future where coverage and security are guaranteed for all while the cost doesn't get out of control.
As they have this discussion, Democrats will benefit from the fact that public sentiment has moved decidedly in their direction. It isn't just that approval ratings of the ACA improved as the Republican effort to dismantle it made people realize what it had accomplished. It's also that the presumptions underlying our health-care debate have changed. As Jonathan Cohn notes, the ACA "has shifted the expectations of what government should do ― and of what a decent society looks like." Republicans found, to their evident surprise, that the idea that everyone in America has the right to health care has now been accepted by the public, and no "reform" that treats health care like a privilege will succeed.
Democrats believed all along that health care is a right. It will take some time — perhaps years — for them to settle on a program that they want to enact. They have the opportunity and the obligation to start building now for the next time they have the power to take the next step in bringing the American health-care system toward something resembling sanity. Goodness knows, if they don't do it, nobody else will.
