The American health care system is once again in the center of a political maelstrom.
As the Trump administration called for the total invalidation of the Affordable Care Act in a court case now pending before the Fifth Circuit Court of Appeals, Democrats in the House have pledged to fight in Congress and the courts.
They introduced bills to defend the ACA and cut costs that continue to limit access to care for many Americans. At the same time, many progressives in the Democratic Party are calling for even more sweeping reforms.
Democrats understand there's no chance to enact more expansive legislation without control of the White House and Senate, but debate over how to proceed in the future is well underway. Two pieces of legislation — one led by Sen. Bernie Sanders, the presidential candidate from Vermont, would create a single-payer system, or a Medicare-for-All that would replace private insurers with a taxpayer-paid government insurance.
Two bills would allow people between the ages of 64 and 50, in one case, or 55 in another, to buy into the Medicare system. Four bills would create a public option for individuals and some or all employers, based on Medicare, while another would let states give residents the option to buy into Medicaid.
Meanwhile, legislators, including many Democrats from swing or moderate districts, are focused on shoring up the Affordable Care Act, the controversial program enacted in 2010 that now subsidizes health care for millions of Americans, including those in New York State's popular Essential Plan for moderate-income individuals.
Proposals for Reforming Health Care
Medicare-for-All, Single-Payer Plans
Four Public Option Plans
Two Medicare Buy-Ins for Older Americans
Medicaid Buy-In Plan for States
Its consumer protections include coverage for pre-existing conditions, comprehensive coverage that covers drug treatment and mental health care, children allowed to remain on parents' policies up to age 26 and a ban on annual or lifetime coverage caps. But rising costs have angered individual policyholders who don't qualify for subsidies, in a costly health care system that increasingly relies on high deductibles and out-of-pocket expenses.
President Donald Trump tweeted that all Republicans support protections for pre-existing conditions and said this week that the Repubican Party "will soon be known as the party of health care" but has not offered a plan that would do so.
Still bitter over the failure of Congress to repeal the ACA in 2017, his decision to back the complete overturn of the ACA in court nonetheless surprised many observers. Democrats won control of the House of Representatives last November in part because of voters' concerns over losing health care.
Now some congressional Republicans are no longer talking about ACA repeal. Republican Rep. Peter King (R-Seaford) is one.
He said he opposed the ACA and would still be against it. But the 14-term representative from Long Island's 2nd Congressional District said he accepts that "the medical system is premised on it" and that its sudden revocation "would be disastrous" for state and local governments and hospitals. He wants to find ways to help middle-income people with high premiums and deductibles and policies they didn't want without "bankrupting the plan," he said.
"Both parties have to accept something," he said. "We're not going to repeal and replace Obamacare but we can correct it ... I think Republicans caught a lot of heat in the last election because of existing condition arguments so Republicans are more willing to discuss reforms rather than outright repeal."
Rep. Thomas Suozzi (D-Glen Cove), who represents Long Island 3rd Congressional District and recently joined with King in proposing a bipartisan approach to immigration reform and border security, also took a "mend it, don't end it" approach to the ACA, with an emphasis on preventive medicine.
"It has problems but it's much better than anything else proposed by the other party," he said. Suozzi is also a co-sponsor of a bill to extend Medicare-type coverage to those aged 50 to 64, and sees the value of cutting out the administrative costs of private health care insurers, which is a goal of the single-payer plan.
Polls show a wide level of approval for expanding Medicare or even single payer, but support drops when people learn their own private insurance would disappear in a single-payer system, and taxes would rise — although health care costs overall might drop by cutting out the insurance company's profits and administrative burdens.
"The starting point is where do people get their insurance now: 180 million get insurance through their employers and most people are satisfied," Suozzi said. Single payer "would cause major job disruptions and disruptions to the medical system. The good news here is there is a lot of energy behind reforming the system and I encourage that."
Rep. Kathleen Rice, a Democrat who represents Nassau's 4th Congressional District, said that while it was important to "explore all options that would get us to our shared goal of universal coverage," for now she was focused on preserving and improving the ACA against "this President's relentless assault on our health care system ...This week we took a major step in the right direction by introducing legislation that will protect people with pre-existing conditions and lower premiums."
The difficulty of achieving any consensus on health care reform is reflected in the spectrum of positions favored by stakeholders: hospitals, physicians, insurers, governments, unions and business groups.
Hospitals, insurers, drug companies, and some medical groups do not favor single-payer health care, (and are lobbying heavily against it) while some groups representing physicians, nurses, and health care unions do.
"Medicaid and Medicare pay less than the cost of care: 74 cents on the dollar for Medicaid and 87 cents on the dollar for Medicare," said Janine Logan, spokeswoman for the Suburban Hospital Alliance of New York State, representing 50 hospitals in nine counties including Nassau and Suffolk. "Whereby commercial insurance pays the cost of care and then some depending on negotiated reimbursement contracts. So that becomes problematic." She said less money in the system meant less innovation, and facilities unable to meet their costs.
"Does something need to be done? Yes, incrementally," she said.
Even groups that support Medicare-for-All agree on their support for incremental steps to cut costs and broaden access.
"I am in favor of anything that moves us in the right direction," said Dr. Marc Price, president of the New York State Academy of Family Physicians, which voted to support legislation to create a single-payer system in New York State while also supporting collective bargaining by doctors. "Interim steps are wonderful. I'm not one who thinks this will happen overnight."
Price said single payer would ease the administrative burdens on practices like his, which must now comply with the paperwork demands of multiple insurers. "It doesn't matter to me how you get there but some kind of improved health care In this country is necessary," he said. "Some kind of universal health care whether it's privatized with regulation, versus government funded or government run, we deserve better. Is health care a right or a privilege. If it's a right we should all have it."
Charles Rothberg, a Suffolk County ophthalmologist and past president of the state Medical Society of the State of New York, said the group supported multi-payer systems although a significant number of members did support a single-payer approach. He warned of unintended side effects when doctors are not able to negotiate rates high enough to stay in business and that if independent practices like his are forced to close or join hospital practices, access to care will be narrowed.
"My concern is we'll pass single payer and we'll be forced to accept whatever elected officials shove down our throats and we won't have anything else to fall back on," he said. "One of the good things about single payer is you get 100 percent coverage but we are within striking distance already. Critics might ask do we have to revamp an entire system to get at that five percent who are not covered (in New York State) and that is a reasonable question."
Helen Schaub, New York State director of policy and legislation for 1199SEIU, a union representing health care workers, said it also supported a single-payer system. "You have a lot of waste and unnecessary complexity in the current system. None of which is related to the delivering of health care." But, she added, "We also believe that anything we can do to make health care better for people right now, more affordable with more access to high quality health care from their local providers we should be doing ... We see every day the impact of people not having (universal health care)."
Cristina Batt, Healthcare Association of New York State's vice president for federal affairs, an organization with 500 members including hospitals, nursing homes, home health care agencies and other health care providers, said affordability was at the core of the health care discussion.
."You see the Senate taking steps to look at the cost of prescription drugs," she said, noting an appetite to reduce costs on both sides of the aisle. "I believe there is legislation on the House side to expand and enhance subsidies (which) would help lower costs for Americans."
She added, "I'm not sure if it's going to be as transformative as Medicare for all. But that's this year. In two years we may be talking about a whole new set of lawmakers and a different environment."