Democrats Already Have a Healthcare Playbook for 2029

As the midterm elections approach, politicians are debating healthcare within the broader context of “affordability,” or, more precisely, the challenge voters say they are facing in paying their regular bills. An interesting battle within the Democratic Party is underway over the appropriate response to this concern, with some favoring Medicare for All and others voicing skepticism about that approach.


Leading congressional Democrats, including Sen. Ron Wyden of the Finance Committee, are hedging their bets, but the most likely scenario is still one of incrementalism rather than sweeping reform.


Medicare for All has always been more effective as a rallying cry for the Democratic Party than as a roadmap for getting a bill through Congress. Although many voters are exasperated with the state of American healthcare, support for Medicare for All falls when its costs, which are considerable, are made clear to survey respondents. There is also a broad lack of confidence in the government’s ability to competently manage healthcare insurance for the entire country.


A potential guide for what Democrats might do in lieu of Medicare for All can be found in a document posted in July by Wyden on behalf of many of his Senate colleagues. It lists scores of ideas for reforming healthcare insurance and care delivery, including through the possible adoption of Medicare for All, although the balance of the paper points toward more public control and regulation than a major push for a monolithic public plan.


Wyden is following the playbook Democrats used to successfully advance the Affordable Care Act (ACA) from 2008 to 2010. In the months leading up to the 2008 election, then-Senate Finance Committee Chairman Max Baucus had worked with outside experts and fellow Democrats to draft a white paper on healthcare, which he released just days after then-Sen. Barack Obama won the presidency. That document would serve as the blueprint for the bill Baucus would draft and pass in the Senate in 2009, which later became the foundational ACA law.


Many healthcare concepts that are now familiar because of their inclusion in the ACA were promoted in the Baucus white paper, including the individual mandate, new premium subsidies for non-employer coverage for individuals with incomes below 400 percent of the federal poverty line, a large Medicaid expansion, and accountable care organizations, which are provider-led—as opposed to insurer-owned—managed care plans.


Wyden is explicit in his July release that he views the development work conducted by Baucus before 2009 as a model for what he hopes to accomplish in the run-up to 2029. However, he framed the ideas presented in the July release not as proposals he supports but as ideas for which he is soliciting feedback (responses to his “request for information” are due by October 2). It is possible, depending on what occurs in November 2028, that Wyden will publish a more prescriptive plan after the election to signal more clearly his intentions for 2029.


Wyden’s document zeroes in on consumer dissatisfaction with aspects of private insurance and divides the ideas under review into three categories: lowering costs for consumers and making enrolling in insurance easier, removing barriers to accessing care and lowering administrative costs, and regulating the for-profit companies providing insurance and care to patients.


Some of the more noteworthy concepts included in the document include:
reversing most of the budget cuts and regulatory changes implemented during the second Trump administration

developing transition plans that might allow Medicare for All to be approved with less immediate disruption to the current coverage of many Americans

creating an option for states to offer single-payer coverage

creating a nationwide “public option,” sponsored and run by the federal government, that would be offered to consumers buying individual coverage through the exchanges established by ACA and which might use Medicare’s regulations to set reimbursement rates for services or allow the government to negotiate rates with the providers of services in each market
developing new Medicare or Medicaid “buy-in” options that could be offered to all Americans regardless of their employment status and incomes

creating a single online entry point for enrolling in coverage that both those getting employer-sponsored and non-group coverage could use

allowing states to add to essential health benefits based on emerging evidence of effective services
stricter state oversight over premium increases requested by insurance plans, potentially including caps

eliminating deductibles and coinsurance for some “non-shoppable” services, and applying lower limits on total annual out-of-pocket costs based on a person’s income
reinstating the enhanced premium credits in place from 2021 to 2025 that the GOP Congress allowed to expire
allowing the ACA premium credits to go to lower-income workers enrolled in employer coverage, which the current “firewall” prohibits and which might be provided irrespective of the share of the premium paid by workers, and
restricting the business practices of for-profit companies participating in the healthcare industry, including insurance companies, private equity investors, and other “middlemen”


The connecting theme behind these ideas is a publicly regulated system, with the government taking on the responsibility of providing affordable coverage options for all Americans, with cost-sharing that is capped relative to household income. Wyden and other Democrats are willing to consider all manner of new controls and subsidies to ensure these objectives are achieved, but it is of course easier to promise these outcomes than to deliver them. An especially formidable obstacle is likely to be the service providers who believe Medicare and Medicaid’s payment rates are too low to serve as guides for private coverage too. Cutting payments to all providers is easier than designing reforms that more precisely target waste and inefficiency, but the ability of Democrats to overcome industry opposition to payment reductions in 2029, as they did when writing the ACA, is not assured.


In addition, even with some provider cuts, the aggregate federal cost of a plan that includes some of the more prominent ideas in the Wyden plan (not including Medicare for All), could be significant. For instance, the Congressional Budget Office has estimated that rolling back policies that tightened administration of the ACA credits, along with reinstating on a permanent basis the enhancement of the credits originally approved in 2021, would increase projected federal budget deficits by $662 billion over 10 years. Democrats are certain to favor tax hikes on well-to-do Americans in 2028, but it is not yet clear that those potential sources of new revenue would be sufficient to fully offset the most expensive ideas the Wyden document teases.


The heavy investment Senate Democrats are making in the development of their 2029 agenda for healthcare contrasts with the GOP’s approach, which is less focused. The Trump administration released a one-page framework earlier this year (“The Great Healthcare Plan”), but there has been little follow-up and no visible movement among congressional Republicans to approve new legislation.



Republicans should take the Wyden document seriously. If voters opt once again for change in 2028 rather than continuity, it is near certain Democrats will use the power voters granted them to prioritize passage of a major healthcare bill. The GOP could make that scenario less likely to occur if it developed, promoted, and tried to advance an alternative approach. There are multiple sound ideas they could embrace to make healthcare more affordable without excessive reliance on public regulation, such as by allowing consumers to keep the savings when they choose lower-cost insurance and care providers. Refining those ideas and putting them into legislation would put the party in a better position to compete with what is coming from their opponents in both 2026 and 2028.

James C. Capretta is a resident fellow and holds the Milton Friedman chair at the American Enterprise Institute.

https://thedispatch.com/article/democrats-healthcare-obamacare-medicare-for-all/