A battle within the Democratic Party is looming on health care if presumptive Democratic presidential nominee Joe Biden wins and the Senate flips.
In the primary earlier this year, Biden’s plan for a government-run public option for health insurance was seen as the moderate choice, compared with Sen. Bernie Sanders’s (I-Vt.) “Medicare for All.”
But once the arena shifts away from the campaign trail to Congress, where the proposal would have to pass via a narrow margin in the Senate and despite fierce opposition from well-funded industry groups, Biden’s plan would become a daunting challenge to enact.
Surveying this landscape, some Democratic congressional aides and outside health care advisers, who spoke on the condition of anonymity, said they expected the party would 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.
In fact, House Democrats already passed such a bill in June, increasing financial assistance under the health law and undoing some of President Trump’s actions but without a public option. That measure is already written and ready to go, and it also includes provisions to lower drug prices, a top Democratic priority.
But progressives, who already think a public option does not go far enough, reject that approach and say the party needs to be bold out of the gate next year, especially given the economic devastation from the coronavirus crisis, setting up a clash among Democrats.
“It’s definitely too small because it’s not regular time; it’s COVID time,” Rep. Pramila Jayapal (D-Wash.), a top progressive in the House, said when asked about a more modest approach of fixes to ObamaCare.
A Senate Democratic aide, though, noted 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.
The aide said any legislative action on health care would take time and recommended that Biden start by highlighting executive actions he can take to roll back Trump moves that Democrats have said undercut the health care law.
Sen. Debbie Stabenow (Mich.), the No. 4 Senate Democrat, said in an interview that the party will “have to assess” how far to go in the first health care bill next year. But “we should be as big and bold as we can,” she said.
“American families by next January or February are going to be feeling even more hardship,” she added, noting the toll of the coronavirus.
The Biden campaign did not respond when asked whether a President Biden would push for a public option right away or start with a smaller bid on health care.
The campaign has a large group of outside advisers on health care, many of whom are former Obama administration health care officials, who have been holding conference calls and breaking into subgroups to start developing more of the policy details.
But people familiar with the effort said it is more about keeping people engaged and coming up with policy options that would eventually be passed on to the transition team and the new administration rather than coming to any decisions at the moment.
Powerful health care industry groups, ranging from drug companies to health insurers to hospitals, are strongly opposed to a public option, worried about its impact on their bottom line, and would fight any legislative push on the subject next year.
The industry is instead pushing the idea of a more modest ObamaCare fix that does not include a public option.
Lauren Crawford Shaver, executive director of the Partnership for America’s Health Care Future, an industry group fighting the public option, pointed to the bill House Democrats passed in June as a better alternative.
“We’ve got to strengthen what we have,” she said.
A health care industry source said many in the industry are expecting that Democrats would start with fixing the Affordable Care Act (ACA) without a public option.
“The easy win is fixing the ACA, expanding the tax credits,” the source said. “I don’t know any sector of the industry [that] will lobby against an ACA fix.”
In contrast, the industry would fight a public option. Crawford Shaver said her group will soon be increasing its advertising against the idea.
If Democrats do take back the Senate, they would likely hold control of the chamber by only a couple of seats, giving veto power to more moderate members of the caucus such as Sens. Joe Manchin (D-W.Va.) and Kyrsten Sinema (D-Ariz.).
Asked if the senator supports a public option plan along the lines of the one proposed by Biden, Manchin communications director Sam Runyon did not answer directly but said, “Senator Manchin has long said the Affordable Care Act is in need of repairs. He trusts that Vice President Biden will be willing to work with the entire caucus as he has been throughout his entire career.”
Sinema’s office did not respond to a request for comment.
Much of the landscape in the Senate next year on health care will depend on the state of the pandemic. Early legislative action could still be needed on areas such as testing or vaccine distribution or on economic measures to stem the steep job losses.
There is also the question of the filibuster. Republican votes are not expected for basically any Democratic health care proposals, including expanding ObamaCare without a public option, and Democrats will not have the 60 votes needed to clear a filibuster.
The push to abolish the filibuster altogether has gained some ground, getting a boost from former President Obama last month, but it is still far from clear that Democrats would abolish it early next year. Democrats could have to use the special procedure known as reconciliation to bypass the filibuster, meaning they could be limited to just one major health care bill, as there are limits on how often that process can be used.
Speaker Nancy Pelosi (D-Calif.) said in a video interview with The Washington Post in June that under full Democratic control next year, “our first priority will be what it’s always been, the first priority in America’s households: health care.” She did not elaborate on what specifically Democrats would propose on the subject, though.
Rep. Robin Kelly (D-Ill.), a member of the “unity task force” brought together to help bridge the ideas of Sanders and Biden, said that while some details may need to be worked out next year on the health care push, industry should know change is coming under full Democratic control.
“They know if it’s Democrat, Democrat, Democrat … things are not going to be the same,” she said.