Health Reform Realism


In noticeable ways our current health reform period resembles the 2005-2006 era when political leaders, stakeholders, and think tanks began formulating proposals to prepare for a future national effort to achieve comprehensive health reform, a process that came to fruition with the signing of the Affordable Care Act (ACA) in March 2010. Though those years were also a time of unitary Republican control of the White House and both houses of Congress, many foresaw the arrival of a new president and Congress in 2009 as a potential and not-to-be-missed window of opportunity for important reform. Waiting until 2009 to begin planning would have been too late. I propose that in 2018 we embrace this renewed possibility for reform with realism and humility.

Today we already see a plethora of legislative and policy proposals emerging from elected Democratic officials and progressive think tanks such as the Urban Institute and the Center for American Progress. While Sen. Bernie Sanders’s Medicare for All bill seeks the holy grail of single-payer reconstruction, others aim for meaningful yet incremental changes to address critical pain points in the current system.

All of these plans rely on an unreliable expectation that, come January 2021, Democrats will control the White House and governing majorities in the US Senate and House of Representatives, as the federal election cycles of 2018 and 2020 come to resemble the blue-wave cycles of 2006 and 2008. All of these plans recognize little potential for meaningful reform until then. However, if Democrats control all 3 power sources come January 2021, public demands on them for far-reaching national health reform may well be overpowering.

I suggest a more temperate health reform agenda, based in part on my vivid memories of working in the US Senate during the 2009-2010 health reform campaign that led to the ACA’s passage.

Back in 2008, Democratic politicians, especially then–presidential candidate Barack Obama, made numerous promises to many groups, few more insistently than the promise to pursue universal health insurance for all Americans. Other important constituencies received promises as well—notably, advocates for comprehensive immigration reform.

But the process of passing major national health reform legislation sucks up most of the political oxygen in the room, leaving little time or capacity to pursue other key societal objectives that require Congress’s consent. Yes, the Dodd-Frank Wall Street Reform and Consumer Protection Act was signed into law in July 2010, 4 months after the ACA’s signing. But that was it for post-ACA major legislation in a period when President Obama had solid Democratic majorities in the Senate and the House of Representatives.

As the Obama administration took charge in 2009, and as health reform grabbed the front of the agenda, immigration reform advocates were advised by elected officials and their staffs to hold tight—we’ll get to you right after health reform. When immigration advocates insisted on coverage for undocumented immigrants in any health reform bill, they were cautioned to save that objective for a forthcoming immigration reform bill. More than 8 years later, immigration reform remains an unredeemed promise.

I don’t believe that any elected official or staff person deliberately lied. Instead, the surprisingly vociferous opposition to health reform became politically radioactive due to the activism of the newly constituted hard-right Tea Party forces. Many Republican operatives also saw an opportunity to replay the 1993-1994 Clinton Health Reform fiasco, throwing gasoline on the fast-moving fire of anti-ACA opposition and hoping that defeat would contribute to Democrats losing control of both houses of Congress as happened during the Clinton era.

Looking toward 2021, the number of non-health issues that will clamor for attention from a new administration and Congress, regardless of partisan control, will be imposing, including immigration, climate change, gun control, education reform (especially higher education), criminal justice, voting rights, economic justice and tax policy, government ethics and conflicts of interest, infrastructure, foreign policy, and many more. Achieving any of these will consume substantial political capital.

If there is a pathway to address the well-recognized flaws and weaknesses in current health policy that avoids a replay of the Clinton and Obama health reform wars—which a Sanders-style single-payer plan would provoke, even more so than did the ACA—does it not make sense for a bit of modesty regarding health reform? What might a more modest yet meaningful health reform agenda look like? I recommend 2 proposals, one advanced by Sen. Elizabeth Warren and the other by the Urban Institute.

Warren’s proposal, the Consumer Health Insurance Protection Act of 2018, focuses on improving the affordability and reliability of health insurance in a more durable and expansive way than devised in the ACA.1 The legislation would address significant affordability gaps in the ACA by ensuring that no household, regardless of income, would have to pay more than 8.5% of income on premiums (now as high as 9.5% for families with incomes up to 400% of the federal poverty line and without affordability limits for families with incomes above that line).

Warren’s bill also addresses other recognized weaknesses in the ACA structure. For instance, her plan would curb excessive consumer cost sharing by basing protections on the ACA’s more generous “gold-tier” level and by capping out-of-pocket cost sharing for prescription drugs at $250 per month for all privately insured Americans. The legislation also would reverse deliberate damage done to the ACA by the Trump administration, for example, by reinvesting in enrollment support to assist Americans who need help in signing up for coverage. It would require insurance companies that participate in Medicare Advantage and Medicaid to also offer plans in ACA marketplaces where current plan choices are limited.

Similarly, the Urban Institute proposal, the Healthy America Program, would build on successful features of the ACA and Medicare, with a bolder twist than Warren’s bill, by merging the ACA’s private-coverage marketplaces with the non-elderly portions of Medicaid and the Children’s Health Insurance Program (CHIP) in ways that would strengthen all three.2 The plan allows continuation of employer-sponsored insurance for participating employers and provides options for coverage through the new structure. Importantly, the plan would eliminate the incessant and pervasive “churning” of coverage for lower-income Americans between Medicaid and ACA exchange plans.

One common theme among most of the new proposals is use of the word Medicare in bill titles. Four different proposals by senators (Bernie Sanders, Tim Kaine and Michael Bennet, Chris Murphy and Jeff Merkley) and the Center for American Progress follow this theme. Polling shows that the public significantly prefers using Medicare to the term single payer as a descriptor. According to a November 2017 poll, 62% of respondents had positive reactions to “Medicare for All” while only 48% had that reaction to “single payer.”3 No wonder Democrats now regularly use the former term and Republicans exclusively use the latter.

One reliable reality of major national health reform legislation in the United States is intense partisan conflict. If a window of opportunity opens for national reform in the future, Democrats and progressives would be wise to proceed with realism and humility for the sake of other urgent national priorities and for the sake of health reform itself.


1. Consumer Health Insurance Protection Act of 2018, 115th Cong, 1st Sess 2018. Accessed June 5, 2018.
2. Blumberg L, Holahan J, Zuckerman S. The Healthy America Plan. Washington, DC: Urban Institute; May 14, 2018. Accessed June 5, 2018.
3. Kaiser health tracking poll—November 2017: the politics of health insurance coverage, ACA open enrollment. Kaiser Family Foundation website. Published November 17, 2017. Accessed June 5, 2018.

About the Author

John E. McDonough, DrPH, MPA, is a professor of public health practice at the Harvard University TH Chan School of Public Health in the Department of Health Policy and Management. Between 2008 and 2010, he served as a senior adviser on national health reform to the US Senate Committee on Health, Education, Labor, and Pensions, where he worked on the writing and passage of the Affordable Care Act. Between 2003 and 2008, he was executive director of Health Care For All, a Massachusetts consumer health advocacy organization, where he played a leading role in the passage of the 2006 Massachusetts health reform law. From 1985 to 1997, he was a member of the Massachusetts House of Representatives where he cochaired the Joint Committee on Health Care. His articles have appeared in the New England Journal of Medicine, Health Affairs and other journals. He has written several books including Inside National Health Reform in 2011 and Experiencing Politics: A Legislator’s Stories of Government and Health Care in 2000, both by the University of California Press and the Milbank Fund. He holds a doctorate in public health from the University of Michigan and a master’s in public administration from the Kennedy School of Government at Harvard University.

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