If one issue dominated the Democratic presidential primaries this cycle, it was health care. Bernie Sanders’s Medicare for All proposal set a standard that other candidates vied to match while simultaneously striving to not commit to as generous a plan. Debate moderators asked endless variations of the same question: How will you pay for it? The more moderate candidates, including Joe Biden, attacked single-payer with criticisms that often veered into the territory of inane lies. But now that the anti-single-payer wing has prevailed and Joe Biden is the nominee, a new question has arisen: Will the patchy, cut-rate health care proposal that Biden promised survive beyond Inauguration Day?
The outlook is not so good. Over the last week, ominous signs have emerged that should trouble anyone who’s counting on Biden to enact the public option plan that he offered as an alternative to single-payer. Among them was the notable way that Bernie Sanders’s Democratic National Convention speech did not use the words “public option.” The only specific health care proposal of Biden’s that he cited was a plan to expand Medicare to people aged 60 to 65. Sanders also did not describe Biden’s plan as “universal,” saying only that it would “greatly expand” coverage. Biden himself referred briefly to his proposal in a pre-recorded video during the convention, but his acceptance speech made no mention of a public option.
Reading between the lines of convention speeches might seem like hysterical tea-leaf reading—if it weren’t for other bad omens, like a story in The Hill this week that reported that some congressional Democrats expect to “start next year with a more modest package of fixes to ObamaCare that did not include a public option in an effort to get some early points on the board.” One Senate Democratic aide told the paper that “if Democrats win back the Senate, it will be through red or purple states, and there will be plenty more moderate members in the caucus.” It is all too easy to see a scenario where Biden squeaks into office after weeks of uncertainty relating to mail-in ballots and Republican whining, with a narrow Senate majority, and opts to put those points on the board by passing some narrow amendments to the Affordable Care Act, or ACA—and then somehow just never gets around to passing that public option, what with everything else going on.
As former Bernie Sanders staffer David Sirota wrote in his newsletter with Andrew Perez, these sorts of quotes may be a “trial balloon” for a forthcoming retreat on health care. Sirota noted that the Partnership for America’s Health Care Future, or PAHCF, the industry-run astroturf group that exists to fight any health care reform that might undercut their masters’ profit-raking, announced last Friday that it would run a campaign to dissuade lawmakers from supporting a public option during convention coverage. These sorts of ad buys are aimed at Washington policymakers, not the kind of Real Americans that it pretends are invested in its campaigns. In this case, their rhetoric is centered on scaremongering about the cost of a public option and, as has always been consistent with PAHCF’s messaging, building on “what’s working” instead of starting over with a new “government-run” plan. That is to say, making minor fixes to the ACA is about all that the well-remunerated captains of the health care industry will allow.
The coming effort to drive Biden away from his public option plan will be dependent on some artful deceptions, chief among them being that the public wants Biden and his fellow Democrats to leave well enough alone and not put the tenuous gains of the last decade-and-a-half at risk. But the public very much wants this system to be amended. Millions of Americans cannot afford medication or fear going to the doctor because of cost or to the hospital because of massive bills. The United States spends more on health care for worse outcomes than other countries. The situation in this country was objectively dire before the pandemic arrived and unemployment exploded with millions losing their employer-provided health insurance.
Even many better-off people have a rough time with our health care system. A poll by the Robert Wood Johnson Foundation from January this year found that 30 percent of “higher income” people, defined as making between $100,000 and $499,999 a year, reported trouble paying for health care costs. (Among adults making less than $35,000 a year, 57 percent reported the same problems.) The constituency for maintaining the status quo is very small. Only 36 percent of Republicans “strongly oppose” a public option; just 17 percent of voters overall feel this way. It is hard to imagine where this argument, that the public option is too extreme, will come from other than from industry lobbyists.
Part of the clumsy sleight of hand that is on the way will be pretending that “fixing the Affordable Care Act” is a thing that can be done and that voters actually understand what these repairs would entail. The health care industry will point to polls showing that voters would prefer “fixing the ACA” to “blowing up the system.” But these respondents will only have a vague sense of what these choices entail. They may not realize that “fixing” the ACA would leave intact many of their biggest gripes with the system: savings-draining deductibles, inflated prescription prices, the lack of insurance security for those facing job loss. And those pulling the strings won’t be offering an accurate picture of what they intend to fix or why anyone should support that effort.
A measure passed by House Democrats this past June provides some insight into what “fixing the ACA” might mean. That bill would make premiums on the ACA marketplace—which only covers 11 million people, or 3.35 percent of the population—more affordable by getting rid of the upper-income limit for subsidies and slightly reducing the cap on premiums. It would also fix the “family glitch,” a problem with the law as written where the standard that determines whether employer-based coverage is “affordable” is on individual premium rates rather than family premium rates. This oversight has locked many families out of premium subsidies on the ACA marketplace, even though they can’t afford the family coverage their employer offers. But these matters are difficult to explain to anyone without their eyes glazing over–certainly not the kind of thing that would, in Ady Barkan’s words, inspire people to “get arrested” protesting on behalf of such arcane tweaks.
Other proposed fixes to the ACA have the same problems. Some are easily vilified by Republicans, like bringing back the individual mandate, the tax penalty paid by those who don’t buy health insurance. Wonks agree that the mandate is “critical” to the functioning of the ACA, but it remains the only plank of the ACA that is broadly unpopular (which is fair since it is terrible). Other amendments will be vehemently opposed by powerful parts of the health care industry: A proposal to cap hospital and provider charges, for instance, would send the same dark forces that emerged to kill off legislation to end surprise billing to DEFCON 1 faster than you can say “private equity.”
None of what the industry would allow or offer, if left to their own devices, would provide an adequate solution to the problems that voters say they urgently want. During the Democratic primary, exit polls showed a clear preference for “a government plan for all instead of private insurance.” But Democrats clearly at least want a public option alongside private insurance; otherwise, lawmakers like Biden wouldn’t run on it or win elections backing it. As Sirota and Perez wrote, even centrist Democratic candidates for Senate, like Amy McGrath in Kentucky, claim to support a public option.
The real problem is that Democratic leadership in Congress doesn’t want to upset the health care industry. House Ways and Means Chairman Richard Neal, who’s in a fierce reelection fight, is reported to have killed legislation to fix surprise billing at the last minute; not coincidentally, he has substantial ties to the hospital industry, which despises any effort to amend its fraudulent pricing practices. House Speaker Nancy Pelosi has repeatedly said she supports strengthening the ACA to any other fix and has been caught telling lies about Medicare for All. How can we trust this group of wealthy, industry-beholden liars to listen? Why should anyone have faith that Biden’s resolve to keep his own modest promises won’t disintegrate amid a flurry of advertisements designed to dissuade him?
One of the underrated differences between Biden and Sanders is that the former Senator built his reputation on transactional exchanges in Washington while the latter built his on ironclad principles. This has essentially been the debate of the primary: Which of these traits are best suited to unwind the Trump era? The transactional approach that Biden promised has won the day, but what’s been lost is the inimitable way that when Sanders said he wanted to fight for something, you could trust that he really did want to fight for it—even if he couldn’t win. Moreover, you could trust Sanders to understand his own proposals; Biden has, at times, seemed to not understand his own plan, which makes it harder to imagine he can maintain the passion to get it passed. As my colleague Alex Shephard wrote, policy was an afterthought at the Democratic convention, where it was superseded by the message that Biden’s got this, man. He’s going to restore America’s good vibes by providing “an off-ramp” from the “all-consuming” politics of the past four years. This includes the intra-party political fights that have defined the debate among Democratic factions along with the dreadful ideology that the Trump presidency unleashed.
There are other indicators outside the health care sphere that suggest that Biden’s plan to end factionalism is to largely ignore what the left wants. Ben Harris, a top economic adviser to Biden’s campaign, recently told Vox that Biden intended to try and pass his boldest plans through securing a sufficient number of Republican votes, as opposed to eliminating the filibuster or other parliamentary tricks. “That’s what happens when you spend so many decades in the Senate is you build these friendships and you build these relationships and you build this credibility,” Harris told the site. This is beyond naivety; it is insanity if it is meant in earnest.
The head of Biden’s transition team, Ted Kaufman, has similarly signaled that a Biden presidency would have limited ambitions. Kaufman told The Wall Street Journal this week that “the pantry is going to be bare” for spending on big social programs, saying: “When you see what Trump’s done to the deficit ... forget about Covid-19, all the deficits that he built with the incredible tax cuts. So we’re going to be limited.” Heading into the election already resigned to Washington deficit hackery and chained to the debts created by the very Republicans you’re running against amount to choosing to fail.
The Week’s Ryan Cooper recently wrote that this evidence of Biden’s backpedaling points in the direction of a “failed presidency.” Certainly, if Harris and Kaufman are the sort of people who set Biden’s strategy in office, we would be lucky to see any kind of progress at all, incremental or not. At the same time, however, others claim Biden is considering an “FDR-sized” presidency and that the ravages of the coronavirus pandemic have woken him up to the scale of change needed. If that’s true, Biden will need a Lyndon B. Johnson-style willingness to bully and cajole his party’s caucus along with an FDR-sized resolve to go against the vast power and resources of the industry that has allies on his team and sees him as a pliable helpmate. A president that sees the coronavirus pandemic and the ongoing injustice of health care in this country, and chooses not to fight to fix it, would not just be a failed president; he would be a failed human.