Health care debate returns as ACA subsidies expire and lawmakers weigh options
The renewed fight over U.S. health care is back in Washington as millions of people confront a steep rise in costs after Republican-controlled Congress allowed Affordable Care Act subsidies to expire. The dispute is reviving long-standing grievances about how health care is managed under the ACA, which was passed in 2010 without a single Republican vote, and has remained politically fraught even as it expanded coverage.
Sen. Bernie Moreno, R-Ohio, said he is trying to persuade colleagues who “hate Obamacare” and that his group is aiming to extend subsidies for a limited period while pursuing broader affordability goals. He said, “Let’s take two years to actually deliver for the American people truly affordable health care,” and added that Congress should focus on getting lawmakers to understand what he calls the need for cheaper coverage.
Democrats have responded that Republicans have had time to replace the ACA and that current discussions do not go far enough. Rep. Steny Hoyer, a Maryland Democrat and former House majority leader during the ACA debate, said, “They’ve had a lot of time,” arguing that lawmakers on the other side have repeatedly returned to reforms without delivering a substitute that addresses health care costs.
The politics have followed a familiar pattern, including a legacy of repeated attempts and failures to reach consensus. The story of congressional health legislation stretches back at least to the late 1940s, when President Harry Truman tried and failed to persuade Congress to enact a comprehensive national health care program and later described the outcome as “troubled me the most,” according to the account.
Former White House chief of staff Rahm Emanuel said the central challenge is that many people are angry at the status quo but not confident in what comes next. He said, “People hate the status quo, but they’re not too thrilled with change,” describing the enduring “riddle to the politics of health care” that has kept Washington stuck between dissatisfaction and uncertainty.
Part of the stalemate is that the health system sits at the intersection of policy and economics, with many stakeholders positioned to be affected by changes. Hoyer pointed to the pressure that comes with any attempt to reduce costs, saying, “Any time you try to figure out how to bring costs down, somebody thinks, ‘Uh oh, I’m about to get less,’” as major reforms run into resistance from a wide set of health industry interests, including pharmaceutical and health services companies as well as hospitals and nursing homes.
As Republicans weigh subsidy extensions, Trump’s approach to health care has centered on drug prices and shifting money toward health savings accounts. During his second term, he has criticized Obamacare as unfairly subsidizing insurers, while his latest outline—introduced as “The Great Healthcare Plan”—would not repeal the ACA. Instead, it would emphasize lowering drug prices and allowing Americans to send money directly to health savings accounts to handle insurance on their own, a plan Democrats have rejected as insufficient to address health care costs.
Some Republicans and Democrats, however, have revisited different parts of the policy debate over time, including long-running arguments about whether the federal government should play a larger role. Trump’s aides and supporters have also pointed to the idea of reducing costs without changing the structure of private coverage, while a small group of Democrats has sought to revive debate over a public option that would provide a government-run insurance choice on ACA exchanges.
Democratic efforts have included legislation introduced by Sens. Sheldon Whitehouse of Rhode Island and Elissa Slotkin of Michigan and Rep. Jan Schakowsky of Illinois to create a public health insurance option on the ACA exchanges. The bill faces steep odds in a Republican-controlled Congress, but it reflects how the subsidy question has reopened broader fights about the ACA’s legacy and the role of government in health coverage.
ACA veterans and Democrats who helped craft the law have acknowledged that it has not solved health cost problems. Former Sen. Max Baucus, a Montana Democrat and a chair of the Senate Finance Committee during the law’s development, said, “nothing is perfect,” pointing to high health care costs and adding, “Bending the cost curve, that has not bent as much as we’d like.”
Baucus’s comments come as some Republicans have expressed openness to a deal on subsidies as a bridge, while other negotiators warn that major health reforms take the kind of detailed, extended bargaining that earlier efforts demanded. Rep. Don Bacon, R-Neb., said lawmakers “We need to get to a long-term solution,” but Baucus said, “It takes a long time to figure all this out,” suggesting lawmakers may need more time than politics typically allows.
Moreno, who said he is not yet “been in Congress for a year,” responded skeptically when asked whether he has studied the history of earlier negotiations. He said, “I don’t know s—-,” and added: “What that means is I don’t have scars.”
Associated Press writers Amelia Thomson-DeVeaux in Washington and Ali Swenson in New York contributed.