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Election 2020
February 14, 2020

What Is Next in the Health Care Reform Debate After New Hampshire?

Author Affiliations
  • 1Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
JAMA Health Forum. 2020;1(2):e200196. doi:10.1001/jamahealthforum.2020.0196

The 2020 campaign for US president enters a new phase as attention shifts away from the Iowa and New Hampshire primaries. Democrats remain divided over 2 key questions. First, who is best positioned to defeat President Donald Trump? Second, should the next president’s governing strategy be incremental or transformative, particularly with respect to health care reform? The primary results in Iowa and New Hampshire have narrowed the answer to the first question in a way that seems to be clearly answering the second question: incrementalism is winning.

Yes, Bernie Sanders—one of the original and most outspoken champions of Medicare for All—won the New Hampshire primary and was effectively tied for first place in Iowa. However, more than half of voters in both states instead selected Pete Buttigieg, Amy Klobuchar, or Joe Biden, all of whom have called for building on private insurance, Medicare, Medicaid, and the Affordable Care Act (ACA) rather than dramatically upending the current system.

Elizabeth Warren is the other major proponent of Medicare for All still in the race, but her candidacy is losing ground. It is not yet clear who her supporters would migrate to, but it is not necessarily Bernie Sanders, even though they appear ideologically aligned. Joe Biden’s campaign is also struggling, with his supporters more likely to get behind Buttigieg, Klobuchar, or Michael Bloomberg than Sanders. In its next phase, the race seems to be focusing on Sanders vs the moderate candidates.

Even if the field stays fractured long enough that Sanders is able to secure the nomination, he will not have a clear mandate to aggressively pursue the most liberal aspects of his platform, including Medicare for All. In fact, these positions would be his biggest liability in key Midwestern battleground states. Democrats fear that this general election matchup would mirror the 1972 race, in which George McGovern emerged from the liberal wing of the Democrat Party as the antiestablishment populist nominee, only to be labeled an anti–free-market socialist by the Republican incumbent. Richard Nixon won that race in one of the largest landslides in modern US history. For the general election, Sanders would likely have to scale back his health care reform proposals to assure moderate voters who are worried that upending the status quo would jeopardize their employer-sponsored health insurance.

Even if Sanders is able to win the presidency, the obstacles to enacting a version of Medicare for All will be overwhelming. Interest groups representing labor unions, hospitals, insurers, and large employers would fiercely oppose a dramatic restructuring of health care. Democrats may not control the Senate in the future and will certainly not have anywhere near a filibuster-proof majority of 60 votes. The lack of clarity on key policy details amongst Democrats in Congress more closely resembles the situation faced by Democrats in 1993 and Republicans in 2017, in which there was consensus on wanting to do something but not on what to do. Both situations led to major political failures in Congress for the president and his party. By contrast, many of the key compromises that led to the ACA’s enactment had already been made by the chairs of major committees in 2007 and 2008, including that single-payer health care was off the table and reform would be modeled on the state health care reform law enacted in Massachusetts in 2006.

Nonetheless, Bernie Sanders’ influence on the future of health care reform has been profound, regardless of whether he wins the nomination or the presidency. He made Medicare for All a major part of the campaign conversation to a degree that seemed impossible a few years ago. This position may have opened the door to such a reform in the long term, and in the near term, it has certainly shifted the landscape of what is considered moderate. Policies such as a public option were considered too liberal in 2010 to be included in the ACA, even with a 60-seat Democratic majority in the Senate, but they are now likely to be the compromise ideas that Sanders, Buttigieg, Klobuchar, or any other Democrat would land on if he or she is elected president.

There is still a long way to go in this election. To put the timeline in perspective, we will know who wins the next Stanley Cup, National Basketball Association finals, and even the World Series before we know who will be sworn in as president at the inauguration next January. But it is becoming increasingly likely that the next push for health care reform, if it occurs in 2021, will be incremental rather than transformative.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: David K. Jones, PhD, Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany St, Boston, MA 02118 (dkjones@bu.edu).

Conflict of Interest Disclosures: None reported.

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    1 Comment for this article
    Comprehensive Healthcare Reform
    Paul Nelson, M.D., M.S. | Family Health Care, P.C. retired
    Among many issues, we should not ignore the fundamental problems that plague our nation's strategy to finance undergraduate and postgraduate medical education. Here is the ultimate social dilemma faced by a person entering medical school: four years hence with a 6 figure debt and unable to match with a residency of my ultimate preference. Is it possible that this conundrum has an impact on a person's choice of professional commitment?