Democratic mayor, governors shaping 2020 debate with moves toward universal health care

WASHINGTON (Sinclair Broadcast Group) — Democrats at the city and state level are setting the stage for the 2020 election and driving the health care debate with plans to provide free care or expanded, government-run health insurance coverage.

In California, Washington State and New York City, newly elected and re-elected Democratic politicians have outlined ambitious plans that could further push Democrats to embrace a universal, single-payer or Medicare for All form of health care system.

In both New York and Washington, the plans are being proposed by politicians rumored to be seeking the Democratic Party's 2020 presidential nomination.

Last week, New York Mayor Bill de Blasio rolled out his proposal for NYC Care, a program to guarantee free medical care to New York's 600,000 uninsureds, asserting, "Health care is a human right and in this city, we're going to make that a reality."

On Sunday, de Blasio indicated that he was considering running for president. In an interview with CNN, he said he had not ruled out the option and signaled a desire to push the party further to the left."I want to push this whole party, and I want to inform this debate in this country about the fact that we could go a lot farther, we can be a lot bolder than what we’re doing now," he said.

Gov. Jay Inslee of Washington, who is also is also considering a bid for the White House, announced his proposal for a state-run public option last week. "We are on the knife’s edge," Inslee said, pointing the blame at the Trump administration for undermining the Affordable Care Act. "And we need to give a solid foundation of support to every county and every citizen in the State of Washington because that is a moral imperative."

Also last week, the newly-elected Governor of California Gavin Newsom unveiled his budget which included plans to expand the statewide health program to cover undocumented immigrants up to the age of 26, while expanding middle-income residents' access to the "Obamacare" exchange.

At the federal level, it is hard to find a prominent national Democrat advocating anything less than a single payer or Medicare for All system, particularly among the list of some two-dozen potential Democratic candidates for president.

"This is what you do if you're a progressive Democrat in 2019. You need to establish your single-payer bonafides," said Tim Rice, deputy director of of health policy at the Manhattan Institute. "You need to do it early and you need to do it often and de Blasio has checked the box."

The recent steps toward free or expanded government-run health care raise the stakes for other politicians, many of whom will be vying for the more progressive position during the Democratic primaries. "You have to have done something," Rice said, noting the politicians who have introduced legislation or enacted some form of Medicare for All at the state or local level will have the advantage. "You can't just talk a big game in your campaign speech without having something to show for it."

New York City will start rolling out its program this summer and in California and Washington, the proposals still have to pass the state Legislature. Even if these politicians hope to influence the 2020 health care debate, the public won't see any of the results until well after the election.

"These won't be implemented in any detail before we start seeing primaries next year," said Michael Tanner, a senior fellow at the libertarian Cato Institute. That means, no results about the effectiveness of the program from a public health or fiscal standpoint.

"The problem in health care is that nobody in the entire system can say no," Tanner continued. "These mayors and governors are promising all manner of benefits far in excess of anything traditional health insurance pays, far in excess of what Medicare pays, and they're ignoring the fact that it's going to cost more money."

NEW YORK CITY'S FREE HEALTH CARE

De Blasio's NYC Care plan essentially builds on an existing program where uninsured New Yorkers can access health care in city-run facilities. Unlike other proposals, NYC Care is not a health insurance program but essentially free health care services for the 600,000 residents who are uninsured.

Under the plan, those who are either unable to afford health insurance or are ineligible for government insurance, such as undocumented immigrants, can receive an array of health care services at either no cost or on a sliding scale. The services include everything from primary care, hospital care, mental health and substance abuse treatment, to specialty care.

According to de Blasio's administration, the program will cost $100 million per year. On average that would provide $167 in health care spending per uninsured person, which critics have denounced as entirely unrealistic.

"You don’t have to be a health-care actuary to guess that $167 won’t go very far toward covering even a healthy person’s insurance costs," Rice wrote of the proposal. According to one study, per capita health spending in New York topped $6,000.

The NYC Care rollout will start this summer in the Bronx and is expected to reach the rest of the burroughs by 2021.

WASHINGTON STATE'S PUBLIC OPTION

Gov. Jay Inslee announced his plan last week for a public option that he believes will help many of Washington's 522,000 uninsured get coverage.

The details are being worked out in the state legislature, but the overarching idea is for the state to contract with a private insurer who will provide a public health option. The more affordable public plan would compete with private insurance and the ACA exchange plans.

“With volatility and uncertainty at the federal level, the goal of this proposal is to provide a sensible alternative that is affordable and accessible in every county," said Washington State Rep. Eileen Cody, one of the sponsors of the Cascade Care bill. In 14 counties, residents have only one choice on the government health exchange, the public option would provide another.

Critics on the left have attacked the public option as not progressive enough and Gov. Inslee could face challenges on the right from Trump administration. While the administration has advocated for more competition among private insurers, it has looked “somewhat less favorably on proposals that would expand public coverage,” explained Jennifer Tolbert, the director of state health reform at the Kaiser Family Foundation.

State officials have estimated it will take $500,000 to set up the new system. Beyond that, it is not clear how much the program will cost to administer. Washington is running on a budget surplus and according to Inslee's latest budget, the state will increase spending by $10 billion over the next two years on priorities like climate change, affordable housing and health care.

CALIFORNIA'S ACA, MEDI-CAL EXPANSION

Immediately after being sworn into office last week, Gov. Gavin Newsom outlined his proposal to dramatically expand health care coverage to roughly 138,000 young people living in the country illegally and to middle-income Californians who earn too much to qualify for the Affordable Care Act tax credit.

“No state has more at stake on the issue of health care. California must lead,” Newsom said in his inaugural address. He continued, "We will use our market power and our moral power to demand fairer prices for prescription drugs. And we will continue to move closer to ensuring health care for every Californian."

Newsom also signed an executive order creating a single-purchaser system for prescription drugs. This will allow Californians and private companies to negotiate prescription drug prices, rather than individual suppliers dealing with individual companies and hospitals.

The ACA tax credit only applies to individuals making 400 percent of the federal poverty level. In California, the credit will be extended to those making between 400 and 600 percent. To pay for the expansion, Newsom will be reinstating the individual mandate, the "Obamacare" provision that required everyone to buy insurance or pay a fine.

The individual mandate was waived nationally in the Republican's 2017 tax plan, but a handful of states are bringing it back to pay for expanded coverage, including California, Massachusetts, New Jersey, Vermont and Washington, D.C.

The Democratic-controlled legislature will debate Newsom's budget and the health care proposal over the coming months.

HIGH COST FOR A POLITICALLY POPULAR IDEA

For years, states have tried to make free or universal health care programs work but inevitably ran up against the impossible challenges of paying for them.

In North Carolina, a Democratic legislator killed her bill last year after analysis indicated the program would cost between $72 and $101 billion in the first year, as much as four times the state's $23 billion budget.

Similarly in Vermont, the state passed a single-payer health care plan in 2011 but had to abandon the idea three years later after the cost estimates showed the program would cost about $4.3 billion per year, nearly 90 percent of the state budget.

New York ended the 2018 fiscal year with a $2.6 billion surplus and intends to reinvest that into health care, including pouring roughly $1.8 billion in subsidies into the city’s public hospital system.

California is also facing a substantial budget surplus of $15 billion. Again, while the cost of Newsom’s ACA and Med-Cal expansion are not yet known, the program is likely to be less expensive than California’s failed universal health care proposal, which was killed by the legislature after estimates showed it would cost $200 to $400 billion to administer.

The costs at the federal level are even more daunting. Vermont Independent Sen. Bernie Sanders' Medicare for All bill showed universal health plan would cost the federal government $32 trillion per year, or about $2.8 trillion more than it is currently spending, according to a study by George Mason University's Mercatus Center.

Changes to the health care law have stalled in Washington, D.C., opening the door for state and local leaders to take matters into their own hands. "This is a way of getting people health care here and now, regardless of what happens at the state level or at the federal level," de Blasio said at a press conference last week.

After the Trump-led "Obamacare" repeal and replace effort failed in 2017, states have increasingly been looking for opportunities to pick up the slack left by the Affordable Care Act and some of the Trump administration's policy reversals. "To the extent states are moving forward, it begins to highlight some of the issues and some of the remaining gaps around affordability and availability," Tolbert said. "I think states are certainly signaling the direction they want to go as we move toward 2020."

Democratic candidates in 2020 will have strong support for universal health care. A poll taken before the 2018 election showed that 70 percent of Americans support Medicare for All, including a majority of Republican voters.

Whether that enthusiasm translates into a new U.S. health care system is debatable. "This is a Congress that can't reopen the federal government," Tanner noted. "The idea that they're going to pass the transformation of the entire health care system, no, it's not happening."