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The health policy debate is about to change completely: There has been disproportionate focus on “Medicare for All”

Written by Timothy McBride, PhD, MS, Bernard Becker Professor at the Brown School and co-director of the Center for Health Economics & Policy at the Institute for Public Health

The 2020 election is well underway and health policy seems to have dominated the debate so far, in many ways.  This has surprised some people, and it is raising some worries among Democratic strategists.

It is also frustrating many analysts who study health policy, who find that the “debate” is missing the mark.

But the debate over health policy is about to change completely. To date, the discussion has centered on a broad issue: to enact “Medicare for All” or not.  But this will not be what we will be discussing in a few weeks. Why not? Because in just a few weeks, it appears likely that a decision in an appeals court decision before the Fifth Circuit Court of Appeals, Texas vs. Azar, may be announced.

This lawsuit, filed by 18 state attorneys general (including the Attorney General at the time in Missouri, Josh Hawley, now that state’s Senator) is the latest challenge to the Affordable Care Act (ACA).  But unlike other lawsuits, this one asks the courts to declare the ENTIRE LAW unconstitutional.  If the Circuit Court agrees – which many Court watchers think will happen – then suddenly a hurricane will hit the 2020 election.  In other words, the debate will move from the question: “should we enact Medicare for All or not?” to “How can we save Obamacare, and should we save Obamacare?”

This was indeed the landscape on which the 2018 election was fought. In that election, the possibility that Republicans would still seek to “repeal and replace” Obamacare was still being debated.  The Democrats used the possibility that, if the Republicans were returned to power in the House of Representatives, they would seek to continue to “repeal and replace” Obamacare, as they had tried to do over 60 times prior to that election, famously coming very close to doing so late in 2017 when Sen. John McCain cast the deciding vote against one of the possible replacement pieces of legislation.

The Democrats concentration on the issue of Obamacare, and how repeal of the ACA could lead to return of bans on pre-existing conditions in health insurance became their leading issue in the 2018 campaign.  When the Democrats took the House back in 2018, many saw this as the end of the campaign to “repeal and replace” Obamacare and in fact the GOP signaled they would stop trying to pass legislation to repeal the ACA.  Work to change the ACA turned to the Courts and to regulatory changes.

So, if the Fifth Circuit declares the ACA unconstitutional what will the outcome be, and what will the impact be on the presidential and other 2020 elections?  I predict the following:

  • Discussion of more substantial changes to the health care system, such as “Medicare for All” will cease to be the focus, and discussion will return to a contrast between the Democrats position on health policy (pro-ACA) compared to the GOP position (anti-ACA);
  • Reporters and pundits will begin to ask Republican candidates and the Trump administration: what is your plan to replace Obamacare now that it has been repealed?
  • The public will begin to understand that repeal of Obamacare not only means repeal of the marketplaces – where most of the focus of the discussion has been – but on many more popular elements of the ACA, such as:
    • the Medicaid expansion in 37 states,
    • the closing of the doughnut hole for Medicare recipients,
    • the ban on pre-existing conditions,
    • the expansion of coverage to dependents
    • and more.

In short, the politics of health policy in the 2020 election will be completely upended. Press reports have suggested that the Trump administration is not ready to reveal a plan to replace Obamacare. They may feel pressure to do so, but the latest reports are that they will announce that they plan to enforce the elements of Obamacare until the Supreme Court decides the fate of Obamacare.  But that will not be likely to happen until after the 2020 election.  But what will that do?  That will simply point out that the composition of the Supreme Court, and how they vote will decide the future fate of Obamacare, the most significant piece of social legislation passed in decades.

Read The Case for Medicaid Expansion in Missouri by Andrew D. Martin, chancellor of Washington University in St. Louis, and David H. Perlmutter, MD, executive vice chancellor for Medical Affairs and dean of the School of Medicine