Democrats at the state level, especially those eyeing 2020, are unlikely to abandon their more sweeping ‘Medicare for All’ goals anytime soon.
Gov. Gavin Newsom wants California to be the first state to offer Medicaid to undocumented adults. Gov. Jared Polis wants Colorado to pioneer a multi-state single-payer system. And in Minnesota, Gov. Tim Walz wants residents to be able to buy into Medicaid.
These radical moves by newly elected liberal governors reveal a new movement among Democrats on health care in advance of the 2020 presidential campaign to see just how far the party will go in pushing universal health care.
The moves are inspired by the Trump administration’s attacks on Obamacare, the legal threats to the law arising from a court case brought by conservative-led states and the shortcomings of the health law itself.
“It’s time to be bold, folks,” Polis said during his first state of the state address. “It’s time for us to build a health care system that makes sense, where market forces produce savings instead of extra costs, where no one has to choose between losing their home and losing their life.”
New Mexico legislators plan to introduce a Medicaid buy-in bill soon after their new session begins next week. Colorado, Connecticut, Nevada, Illinois and Minnesota are all expected to debate versions of a the idea, which would use state money to subsidize a Medicaid-like plan for those who cannot afford health insurance. Washington Gov. Jay Inslee, a prospective 2020 presidential candidate, announced plans for a public option that could lower premiums on the state’s Obamacare exchange.
Newsom, who’s also thought to have eventual national aspirations, said he also wants an individual mandate with revenues used to expand Obamacare subsidies, a step that a few other Democratic-led states have taken. And in New York City, Mayor Bill de Blasio announced he’d devote at least $100 million to increase access to public hospitals and primary care clinics.
De Blasio, like some others, touted his move as universal health care. None of the new proposals go quite that far. Instead, they seek to build on the Affordable Care Act, covering people who do not qualify for Obamacare subsidies and who find the cost of insurance prohibitive.
Democrats at the federal level, especially those eyeing 2020, are unlikely to abandon their more sweeping “Medicare for All” goals anytime soon. But in the states, Democrats don’t want to wait another election cycle before responding to voters concern about access and affordability of care.
“It’s palpable out there, People are worried,” said Trish Riley, executive director of the National Academy for State Health Policy. And that concern, which is showing up in opinion polls and which candidates heard on the campaign trail for the midterms, is encouraging governors and state lawmakers to support broader and bolder ideas.
Connecticut Gov. Ned Lamont ran on a Medicaid buy-in plan. He said during the campaign that his state deserves a governor “who supports national progress toward universal health care and who is focused on delivering tangible results from day one.”
Steve Sisolak, Nevada’s new governor, got an earful about health care costs from voters across the state, said Christina Amestoy, his communications director during the campaign. Sisolak has said he’d consider both a Medicaid buy-in and an individual mandate compelling residents to purchase health insurance.
Now that Obamacare’s penalty for not buying insurance has been zeroed out, at least half a dozen states in all are considering imposing their own individual mandates, though they may not all get through state legislatures. Three states and the District of Columbia already have done so, betting it will get more people in the insurance market and lower premiums.
The moves toward more government involvement are a reaction to the Trump administration’s health care policies and weakening of Obamacare. But they also reflect a desire among Democrats to go beyond the Affordable Care Act. Former President Barack Obama had tried to find a middle ground, enticing Republicans with more market-based solutions. But that never got Republicans on board, and didn’t stem the heated controversy around Obama’s signature law.
“Some of this is frustration with the Affordable Care Act, [which] evoked 10 years of all out political war,” said David Anderson, a Duke University insurance expert. “And if that solution doesn’t work, let’s go to a big government solution because if it’s going to get demagogued either way, this is easier to sell and easier to implement.”
Policies tested in the states often foreshadow national debates. Massachusetts’s 2006 health care law, signed by then-Gov. Mitt Romney, became a model for Obamacare. Hawaii’s decades-old employer mandate and Healthy San Francisco, which raises money from employers to subsidize care, both showed that the government could leverage private business to increase access to health care. And more than two dozen states offered coverage for children before Congress created the Children’s Health Insurance Program in the 1990s.
Legislators believe “our job is to be laboratories and push agendas,” said Riley of the state health policy academy.
The new energy on the left mirrors in some ways the enthusiasm on the right following the 2016 election. More than a dozen states have pursued Medicaid work requirements from the Trump administration, and several more have sought to impose other conditions on coverage for the poor, as the partisan split over who deserves health insurance widens.
The divide was highlighted Wednesday in a Twitter spat between Newsom, who tweeted “health care should be a basic human right,” and Sen. Bill Cassidy (R-La.), who wants to pass legislation blocking coverage of undocumented immigrants and who said “it is not a basic right to come to the U.S. illegally and force U.S. citizens to pay for your care.“
If decisions on expanding Medicaid exacerbated longstanding disparities in support for health care, and recent moves by conservative states widened the gap, liberal states now seem poised to make the differences even starker. Blue states will rely on public money to insure as many residents as practical in a single insurance pool, while red states work to limit public spending on insurance and avoid having healthy residents subsidize coverage for sicker ones.
“You could see some real divergence at the state level, which is encouraged by the Trump administration,” said Sabrina Corlette of Georgetown University’s Center for Health Insurance Reforms.