In health care fight, Democrats wrestle with Obama legacy – and party’s future

Not long ago, the Affordable Care Act was political poison for Democrats. 

The health reform measure’s rocky rollout in 2010 had forced millions of Americans to switch to more expensive health insurance because their old plans didn’t meet the law’s requirements. In poll after poll, President Barack Obama’s signature act met with broad public disapproval. That fall’s midterm elections, which saw the rise of the tea party, were disastrous for Democrats: The party lost six Senate seats and 63 seats in the House of Representatives – as well as control of that chamber.

But by 2018, things had changed. Republicans under President Donald Trump had repeatedly botched their attempts to “repeal and replace” the ACA, as the public’s comfort with – and support for – the law grew. Democratic candidates across the nation, and especially in swing districts, began actively campaigning on “Obamacare.” They vowed to protect people with preexisting medical conditions, ran ads on the issue, and hammered the point home at town halls. 

It worked. In November, Democrats won back the majority in the House. 

Yet less than a year later, as the 2020 presidential primaries kick into gear, many Democrats seem to be jettisoning that hard-won political advantage in favor of a “repeal and replace” option of their own. Many are converging around the idea of a single, government-run insurance system, “Medicare for All,” that promises coverage for everyone, zero out-of-pocket costs, and, over time, lower health care spending overall. In the process, health care policy is becoming the primary arena for a larger fight over President Obama’s legacy – and the future direction of the Democratic Party. 

Over two nights of debates in Detroit this week, 20 candidates vying for the nomination clashed over how fully they were willing to embrace single-payer care. 

On the first night, Vermont Sen. Bernie Sanders and Massachusetts Sen. Elizabeth Warren, the front-runners from the party’s progressive wing, defended their plans to deliver health care from the clutches of greedy insurance companies. Their more moderate rivals accused them of wanting to take away the public’s freedom to choose in favor of an idea that would be mind-bogglingly expensive and disruptive (and, without a filibuster-proof majority in the Senate, would never become law, anyway). 

On Night Two, former Vice President Joe Biden and California Sen. Kamala Harris attacked each other’s health care proposals in a messier version of the previous night’s battle that drew their fellow candidates into the fray. Cost became a sticking point for Senator Harris, while Mr. Biden found himself in the position of defending “Obamacare” – his plan would build on the law’s successes – while distancing himself in other ways from President Obama, now viewed by some in the Democratic base as too centrist for the times. 

It was a stark shift from the party’s unified front on health care during last year’s midterm elections. Protecting those with preexisting conditions, so crucial to Democrats’ success last November, barely came up. Instead, the candidates tangled over policy ideas far to the left of what the ACA ever set out to achieve, like completely eliminating private insurance. 

Some political observers are already raising concerns about yet another health care backlash that could hurt the party’s chances against President Trump in 2020.

“Medicare for All has become a rallying cry and the litmus test for the candidates, and the party has been pushed way to the left,” says Nancy Nielsen, who served as a senior adviser at the Center for Medicare and Medicaid Innovation at the U.S. Department of Health and Human Services under the Obama administration. “If a candidate emerges who embraces that policy approach ... the risk is that [voters] will simply reelect Donald Trump.”

The view from the bar

It’s Tuesday night, and the debate watch party at McShane’s Irish Pub in downtown Detroit is in full swing. Patrons whoop at candidates’ punchy one-liners. Some fill out debate bingo cards handed out by the nonpartisan group Citizen Detroit. The whole place smells like buttered popcorn. 

Betty Bartlett, a retired personnel officer for Wayne County, arrived early with Dianne Harrison, a local teacher’s aide, to secure a hightop table in the crowded bar. Over sodas ahead of the debate, the two friends agree they haven’t decided whom they’d like to be the nominee. What they do know is that health care has gotten too expensive.

“Medicare for All, I think that’d be a good thing,” Ms. Bartlett says. “I take 4 shots of insulin a day, and it’s not cheap.” 

The women’s sentiments track with nationwide polling on health care. Just over half of Americans would favor some kind of national Medicare for All – or single-payer – plan, with about 72% of Democrats supporting it, according to polling from the Kaiser Family Foundation, a health policy research group. Support goes up even more when people are presented with arguments that say such a plan would lower costs and guarantee health care as a right. 

But large majorities also don’t realize how dramatically most Medicare for All proposals would change the way Americans receive and pay for health care. Public support drops when people learn about tax hikes or the possibility of longer wait periods under a single-payer system. 

The same is true for public option proposals, which would create a government-run system to compete with the private health insurance market. About two-thirds of the public broadly say they would favor such a plan, but responses are significantly swayed by arguments around the level of government intervention that would be involved and how it would affect the cost of coverage. 

Buzzy slogans also fail to address a host of other questions that could affect people’s views ahead of the general election. Like: What would happen to long-term care for people with disabilities, which isn’t covered under Medicare? How will unions, typically a Democratic constituency, feel about giving up the employer-based coverage they have negotiated? Would a new system have any effect on prescription drug prices?

Laura Packard, a Democratic digital consultant who became a health care advocate after surviving stage 4 cancer, notes that most of the leading policy proposals wouldn’t kick in until 2025 or later. Folks like her would be uninsurable without the protections guaranteed by the ACA. 

“Debates are important,” says Ms. Packard, who was co-chair of the 2018 Health Care Voter campaign. “But we can’t forget the people who need help right now.” 

“There are things that people are not talking about yet, that they will in the general,” adds Dr. Nielsen, who’s also the senior associate dean of health policy at the University at Buffalo in New York. Democrats “could lose the general election when the populace who is going to vote really understands some of the nuances.”

Vision vs. policy details

On Thursday, former Vice President Biden expressed exasperation with his rivals’ criticisms of “Obamacare” – and the president whose name it bears – as insufficiently bold. “There’s nothing moderate about what Barack did in ‘Obamacare’ – nothing,” he asserted. “No president had come close” to achieving health care reform before that. “They tried and they tried and they tried – seven presidents. This guy did an incredible job.”

So why are so many Democrats seemingly abandoning what had finally become a winning issue for them, in favor of a plan that could once again generate a huge backlash?

“Last year, you were talking to general election voters. Now it’s the Democratic primary,” says longtime strategist Kelly Dietrich. “What matters now is how many Dems you can convince.” 

At this stage in the game, voters are looking for vision, he says, not policy details. Beating President Trump – the top priority for Democrats – means fielding a candidate who can give voters something to believe in and turn out for. 

From this perspective, health care – because it’s so fundamental – makes sense as a vehicle through which candidates try to make that case. Of course there’s the risk of alienating certain voters come November 2020, Mr. Dietrich and others say. But every presidential nominee takes that risk. 

Many candidates said as much on the debate stage in Detroit. 

“It’s time to stop worrying about what the Republicans will say,” argued South Bend, Indiana, Mayor Pete Buttigieg. The GOP will paint the Democratic nominee as a “crazy socialist” no matter what positions he or she takes, he added. “Let’s stand up for the right policy, go up there and defend it.”

Senator Warren made a similar – and similarly well-received – point: “I don’t understand why anybody goes to all the trouble of running for president of the United States just to talk about what we really can’t do and shouldn’t fight for,” she said.

Aaron Hanke, a lawyer for Macomb County Circuit Court and a passionate Democrat, says he couldn’t agree more. On Wednesday night he and his wife hosted a handful of guests in the basement of their home in Fraser, Michigan, just north of Detroit. During a commercial break, as the young couple’s two huskies – Spaghetti and Meatball – scamper around the room sniffing for crumbs, Mr. Hanke explains: “Politics is the art of the possible. ‘Obamacare’ was a compromise – and it’s good. It helped people.” 

“But we’re not done,” he says. “‘Obamacare’ is great, but it’s not the gold standard. Anyone our age who says it is is betraying our generation.”

Staff writer Story Hinckley contributed from Detroit and Fraser, Michigan.