Presidential hopefuls for the 2020 election need to establish their health care reform plans now

The announcements this week by California Sen. Kamala Harris and South Bend, Ind., Mayor Pete Buttigieg that they are seeking their party’s nomination for president in the 2020 election brings the number of Democratic candidates — so far — to nine. But as far as health care is concerned, it’s already 2021 for them. How is that possible? Because presidential candidates are formulating their health care positions right now and, if elected, those positions will heavily influence any health care reform the future president makes in 2021.

Health care is so politically fraught — witness the last nine years of furious combat over the Affordable Care Act — that newly elected presidents who want to do big things, whether it’s expanding or constraining coverage, have to move when their power is at its zenith: the moment they step away from the inaugural podium.

The most skilled legislative president of all time, Lyndon Baines Johnson, understood this well when he gathered his key staff at the White House just after his 1964 landslide win to plan the successful enactment of Medicare and other Great Society programs. Speed, he said, was vital: “Every day while I’m in office, I’m going to lose votes. I’m going to alienate somebody.” The failure of the much-delayed Clinton health plan of 1993 shows the consequences of ignoring Johnson’s advice.

Because of political capital’s short shelf life — the window for health care reform closes six months into a new presidency — newly elected occupants of the Oval Office must have a clear plan when they enter the vital transition months from November to January. Clinton tossed out his staff’s proposal for health reform during a transition meeting in Little Rock, Ark., days before his inauguration. He started his presidency at square one on health policy and never caught up.

Translating these political truths to 2020 presidential hopefuls means that soon after they announce their candidacies — and maybe even before, as they court donors and key staff —candidates, especially Democrats, will have to commit on health care. Those commitments will set the course for their transitions, their critical early months in office, and what’s likely to emerge from their health care presidencies.

So, what should we expect as we look ahead to the 2020 election?

The overwhelming temptation for Democrats will be to embrace “Medicare for all.” It quiets the progressive wing of the party, simplifies our chaotic health system, and achieves Democrats’ long-sought goal — stretching back to Harry Truman — of providing health insurance to all Americans.

But Medicare for all also carries huge political risks for a new president: enormous new taxes, elimination of private insurance for 156 million Americans, and likely fierce opposition from all the stakeholders who have supported the Affordable Care Act, including hospitals, physicians, drug companies, and the insurance industry. Medicare for all will be impossible to enact without massive Democratic majorities in both houses of Congress.

Interesting alternatives to the Medicare for all strategy may be more politically viable. These include various versions of building on the Affordable Care Act by adding options to buy into Medicare (“Medicare for more”) or Medicaid, offering public plans in markets where there is insufficient competition among private plans, expanding financial incentives for buying private insurance, and so on. The presidential primary campaigns must surface these alternatives so voters understand the full range of possibilities — their benefits as well as their risks.

Whatever Democratic candidates decide to champion, voters need to understand that their campaign positions could shape the future of American health care.

The situation for Republicans is somewhat different because their candidate is likely to be a sitting president, and they have already spent several years in the cauldron of congressional health care debate. In the process, Congress — rather than the president — has hammered out a program through the so-called Graham-Cassidy bill that would repeal the Affordable Care Act and replace it with a program of block grants to the states. This means some of the hard work of defining policy options has been done. But that should not lead to complacency.

First, conservative support for Graham-Cassidy is not uniform. The path forward for Republicans will be much easier if their candidate in 2020 runs on a well-defined health care position that telegraphs to the Republican base and voters generally where he intends to take the nation.

Second, the urgency of time will affect a re-elected, or new, Republican president just as it would a Democrat. Graham-Cassidy or its successor will not get enacted unless the newly inaugurated Republican makes it a top early priority. Among the several reasons for the collapse of the Republican effort to repeal and replace the Affordable Care Act was the majority’s failure to define early on their plan for its replacement.

The politics of health care reform can be as complex as the system itself. But you can take one point to the political bank: Presidents who want to transform the U.S. health system must act quickly after they are elected or re-elected, or they might as well not act at all. And that means the early months of our very long presidential campaign season can be decisive for the future of American health care.

David Blumenthal, M.D., is president of the Commonwealth Fund and co-author, with James Morone, of “The Heart of Power: Health and Politics in the Oval Office” (University of California Press, 2010).