How might Democrats respond to another year of health care debate? With Donald Trump as president and a Republican-led Congress, 2017 could be the most tumultuous year for health care since 2010, when the Affordable Care Act was implemented.
Repeal of the law is almost certain in 2017, but what comes after remains to be seen. Both sides of the aisle will have to decide on and negotiate their health care priorities next year as Congress develops a replacement plan for the ACA. Democrats have led the health care conversation for the last few years, but will likely have to take a different approach in 2017.
So as 2016 comes to a close, here are a few health care resolutions for Democrats.
Position Republican proposals as fulfilling President Clinton’s plan
In 2009, former President Bill Clinton made his pitch for the Affordable Care Act to Congress. He urged Democrats to compromise, and encouraged all legislators to just pass the law, and make necessary adjustments over time.
“There is no perfect bill because there’s always going to be consequences,” said President Clinton at the time. “So there will be amendments to this effort, whatever they pass … It’s not important to be perfect, but it’s important to move, to get the ball rolling.”
That insight may be even more important now than it was in 2009. Democrats will be tempted to push back on Republican plans to repeal the law, but should instead rebrand the repeal efforts as simply fulfilling the natural progression of the Affordable Care Act. In other words, that the Republicans simply are doing exactly what Democrats such as President Clinton had in mind when the ACA was originally passed.
Democrats should argue that current Republican “replacement plans” for the ACA, proposed by House Speaker Paul Ryan and Rep. Tom Price, President-elect Donald Trump’s pick for the Department of Health and Human Services, are really not repeals of the ACA at all. Democrats should take ownership over the consumer protections Republicans plan to keep, protections that did not exist before the ACA was enacted.
Republicans intend to keep the ACA’s more popular pieces—protections for people with pre-existing conditions, allowing dependents to stay on their parent’s plan until they’re 26, and even tax credits to offset premiums. Democrats should position themselves as having anticipated tweaks to the law, and are open to improving the ACA over time, just as Clinton predicted.
Coin the term “Lincoln Tax”
Though Democrats should argue that Republican proposals aren’t repeals of the ACA, they still might want to establish a few talking points attacking Price’s and Ryan’s adjustments.
For example, Paul Ryan’s tax cap for employers will likely be a very controversial policy proposal in the coming years. Currently, employers pay no taxes on the health care benefits they provide their employees. Republican policies seek to cap that exclusion, and tax employers for plans that exceed the threshold.
The ACA already provides for this under a provision often referred to as the “Cadillac tax,” an excise tax on “luxury” health plans that exceed a cost threshold.
The Republicans have not indicated recently what they think the cost threshold should be for this sort of tax, but Ryan filed a bill for a similar policy in 2007. His “Tax Equity and Affordability Act” capped the tax exclusion at $11,500 for family coverage and $5,000 for employee-only coverage—well under the Cadillac tax thresholds of $27,500 for family coverage and $10,200 for employee plans.
Employers have been opposed to the Cadillac Tax, which is supposed to go into effect in 2020. Democrats might use the “Tax Equity and Affordability Act” as evidence of what Ryan has previously found reasonable, and ask “You didn’t like the Cadillac tax? Just wait, Ryan’s going to tax your Lincoln—and maybe your Chevy, too!”
Put Republicans in a corner on Medicaid
As with repealing the ACA, Republicans have a clearer path than ever to block-granting Medicaid, changing how the programs are funded. Currently, states receive matching federal dollars for their programs, as long as they comply with federal coverage regulations.
Block-granting would do away with existing federal requirements and give states a lump sum of funding, likely based on how many people a state will cover. There is less federal oversight, and states have more autonomy to run their programs. The argument for this is that states know their populations best, and federal requirements are too “one-size-fits-all” when the reality is that one state’s population can be very different than another state’s population. One argument against block-granting, however, is that some states will cover things, or not cover things, in a way with which the federal government disagrees.
Democrats can put Republicans in a corner on block granting Medicaid by picking one or two politically sensitive requirements that they insist should be enforced for any state to receive its block grant. Including a requirement or two may help pave the way to adding more in the future more easily, as well as helping to score political points.
As an example, Democrats might say, “We are fine with block-granting Medicaid—but think it is important we at least have a requirement in there that if a state is going to cover children with its Medicaid program, the state won’t discriminate against children who live in same-sex households.”
This forces Republicans into a conversation about same-sex households, to which they would likely respond, “This isn’t about discrimination, it’s about allowing states to manage their own Medicaid populations, and giving them the funding to do it.”
Democrats could then ask, “Even if those states are discriminatory? Why wouldn’t we just write in this one protection?”
There are undoubtedly a variety of requirements Democrats could insist on that will be uncomfortable for Republicans to argue against. The point is to avoid a “no-strings-attached” block-grant, by tying the funding to at least one or some requirements. Doing so could make it easier down the line to layer in future requirements and protections that Democrats want.
When it comes to health care, Democrats will be on the defense in 2017. But the above resolutions could strengthen their position, even if Republicans ultimately have the upper hand next year.
Click to read Health Care Resolutions for Consumers, and check back soon for Health Care Resolutions for Republicans.