Senate leader Mitch McConnell has warned Republicans that if he can’t find 50 Republican votes to repeal and replace Obamacare soon, he’ll open negotiations with Democrats to “fix” the thing.
He intended this as a threat - a club to help round up the necessary support among Republicans for his original bill. Now, as push comes to shove, Republican Senate leaders claim they’ll put a marginally revised health care bill on the floor for a vote before the August recess.
With more and more Senators literally besieged by their constituents in Town Hall meetings, and with the current draft registering little more than single digits in popularity, McConnell is finding it harder to round up the Republican votes he needs. As early as next week, McConnell may be reaching out to Democrats to find a bipartisan “fix” for Obamacare.
The Big Fix
A fix is needed, but not because the individual exchanges are collapsing, as Donald Trump frequently claims. It’s needed because the costs for health care for individuals or families forced to purchase on the exchanges are too high and rising. And in increasing numbers of counties, the health insurers are consolidating, leaving consumers with only zero, one or two suppliers. The resulting concentration will insure that prices keep rising.
Democrats claim they are ready to negotiate. All 48 Democratic Senators signed a open letter to Republicans stating that “If repeal [of Obamacare] is abandoned, we stand ready to work with you to help all Americans get the affordable health care they need.”
What should Democrats demand in return for their support?
A few technical tweaks won’t do it. RoseAnn DeMoro of the National Nurses United calls on Democrats to “stand for something,” demand a single payer system and refuse to negotiate. Medicare for all has increasing support from Democrats, but far from a majority in the Congress.
Time to Start Fresh
What progressives should demand is that Democrats require for a vote and debate on Medicare for all. That will not only help educate more of the public about the alternative, it will expose where every Senator stands.
Democrats can’t settle simply for adding subsidies to insurance companies in the private exchanges to sustain competition. Subsidizing insurance companies is noxious in itself, and would do little to help bring costs down.
Democrats should make it clear that any reform has to make the ACA more affordable. Republican proposals to repeal $750 in top end taxes that were part of Obamacare should be torpedoed. Similarly, signature rightwing fixations like expanded health savings accounts, modifying the ratio to lift prices for the elderly, tort reform should be ruled out.
Democrats can’t accept the Republican package with a few add-ons. They need to start fresh with a clean bill.
In a new bill, Democrats should start with first principles:
1. Expand Public Provision
Reforms should move us closer to a single payer, or Medicare for all system. Medicaid and Medicare should be expanded, not cut back. Democrats could insist not only on no cuts to Medicaid and no block granting of the program, they could call for lifting the income level for Medicaid eligibility, making it available to more low income workers. They could also push for extending Medicaid expansion to all states, perhaps by extending the federal assumption of costs for a longer period of time. Democrats could also call for lowering the eligibility age for Medicare. And they should use the negotiation to clear away the regulatory barriers to states seeking to move to a single payer system.
2. Curb Drug Company Excesses
Soaring prescription drug prices anger millions of Americans. The original ACA actually contains an obscene provision that prohibits Medicare from negotiating bulk discounts for seniors. Democrats should insist that Medicaid and Medicare gain the power to negotiate bulk discounts, and enable insurance companies in the exchanges to buy prescription drugs at the same price.
3. A Public Option
Democrats should seek to bolster the exchanges not by shoveling more subsidies to the insurance companies, but by creating a public option to insure competition in every county. The public option could be designed simply to provide subsidies for people on the exchanges to buy into Medicare. At minimum, consumers with no or one supplier in their county should be allowed to purchase insurance from the exchanges that members of Congress use.
4. Subsidize Consumers, not Insurance Companies
Democrats should make plans more affordable not by weakening protection of pre-existing conditions or strong standards on required treatment but by boosting subsidies to consumers, either raising the income levels for eligibility for subsidies or increasing the subsidies themselves. Democrats should also champion aggressive proposals to expand resources to treat the opioid epidemic that is spreading with catastrophic effect.
The Price of Unity
Democrats have remained remarkably unified in opposition to the GOP's obscene bills to "repeal and replace" Obamacare. This will be harder to sustain once bipartisan negotiations open up.
McConnell is no fool. He'll seek to pick off the fewest number of Democrats, and make only the fewest concessions he needs to get a bill passed. Meetings have already begun with more conservative Democrats, like Heidi Heitkamp (D-ND) and Joe Manchin (D-WV).
Democrats should caucus now, work to unify around a proposal and seek the support of a handful of Republicans.
Democratic lawmakers should make certain that they don’t end up signing off on conservative reforms that price millions out of health care.
If Republicans truly want support from their colleagues, Democrats must demand clear, popular amendments that demonstrate they are committed to extend the right to affordable health care, not reduce it.