National

Sen. Joe Manchin (D-W.Va.) said Thursday that Democrats "need to stabilize" Medicare before expanding the program, The Hill reports.

Why it matters: Progressives are hoping to expand Medicare through a broad social spending bill, which Democratic senators have urged Manchin to support. Manchin's vote is critical in passing any Democratic bill in the 50-50 Senate.

House Democrats' $3.5 trillion plan currently includes a provision to expand Medicare to cover hearing, vision and dental health. 

What he's saying: "By 2026, you understand the trust fund is going to be insolvent," he told reporters as he left the Capitol on Thursday. 

"I want to make sure we are stabilizing what we have before we start going down this expansion role."

The big picture: Senate Democrats have not introduced their version of the spending bill, though Sen. Bernie Sanders (I-Vt.) has thrown his support behind the plan.

Disagreements remain on key issues including clean energy and how to pay for the bill, per The Hill.

Manchin is privately saying he thinks Congress should take a "strategic pause" until 2022 before voting on the $3.5 trillion social spending package.

Worth noting: Moderate Democrats like Rep. Suzan DelBene (D-Wash.) have said they prioritize shoring up the ACA before expanding Medicare, according to the Washington Post.

Manchin: "We need to stabilize" Medicare before expanding

The moderate Democrat's comment puts a dent in progressives' hope of expanding Medicare through a broad social spending bill.

Sen. Joe Manchin. Photo: Tom Williams/CQ-Roll Call, Inc via Getty Images

Joe Manchin

Medicare for All

The U.S. faces a range of health care flashpoints — unaffordable drugs, opioids, vaping — as we debate whether to adopt universal care. For now, the Affordable Care Act is the law of the land, but Republicans want to issue it a final death blow.

Health

President Biden has made the COVID-19 crisis and a post-Trump return to national unity and traditional democratic ideals his top priorities. From vaccinations to stimulus to schools, Biden is seeking bipartisan compromise while showing a willingness to use executive authority and bare Democratic majorities in the U.S. House and Senate to implement his policies. Republican leaders are navigating deep party divisions over if and how to move beyond former President Trump.

Politics & Policy

Democrats are exploring adding a huge array of health policies to upcoming spending legislation, ranging from further enhancing Affordable Care Act subsidies to allowing Medicare to negotiate prescription drug prices. 

Why it matters: The next few months may give Democrats the opportunity to walk the walk after campaigning extensively on health care for years, and to plug some of the glaring holes in the system that were exposed by the pandemic.

What they're saying: “It’s not just a moment, it’s the opportunity to address an undeniable set of problems that have been highlighted to a great degree during the COVID pandemic crisis," Democratic health strategist Chris Jennings said. 

Where it stands: President Biden is expected to release his blueprint for a giant package of family-related policies, including health care, in the coming weeks. 

Congress will then have to figure out what to include in actual legislation, with their razor-thin vote margins.

That's no easy task; the 2020 presidential primary was defined largely by the candidates' disagreements on health policy, reflective of the party's divisions. 

Plus, the policies being considered together would likely cost hundreds of billions — if not trillions — of dollars, and some would be viciously opposed by different health industry groups. 

Details: House Speaker Nancy Pelosi is pushing the White House to prioritize a permanent expansion of the ACA's premium subsidies, the Washington Post reports. The last coronavirus package expanded them through 2022.

Additional ACA changes are also being explored, such as tying subsidies to more generous marketplace plans — an idea Biden supported in the primary.

Some Democrats also want to find a way to provide health insurance to poor adults in states that haven't expanded Medicaid, as Politico first reported. 

Biden has already proposed including $400 billion in his infrastructure plan to help provide seniors medical care at home, the WSJ reports.

More controversial moves are also on the table, including lowering the Medicare eligibility age — which Sen. Bernie Sanders is pushing for, per the Post. Hospitals strongly oppose that change.

Sanders is also pressing to expand Medicare benefits to include dental, vision and hearing care.

“It is fair to say there are differences of opinion as to how we prioritize health-care needs," he told the Post.

Between the lines: Democrats want to help pay for these coverage expansions by lowering prescription drug prices, including by letting Medicare negotiate prices.

But that would meet fierce resistance from the pharmaceutical industry, which had an incredibly strong track record of lobbying wins even before it developed coronavirus vaccines.

What we're watching: Passing any combination of the above policies would be a big deal. 

But if Democrats attempt to add a public option into the mix, or remove the firewall between employer coverage and the ACA marketplaces — both of which Biden supported in the primary — the fight with the industry would go nuclear.

Democrats, led by Biden, are aiming big on health care

They're exploring which of a slew of policies to include in a spending package.

Illustration of a donkey pulling a giant health plus. 

Joe Biden

Health care costs

Affordable Care Act

The universal experience of COVID-19 could change how opponents view Medicare for All, Rep. Ro Khanna (D-Calif.) said at an Axios virtual event on Friday. 

What they're saying: "The pandemic has reminded us of our shared humanity with other American citizens. It's no longer possible to think, 'Oh, we're not part of those who get sick.' Now almost everyone knows, unfortunately, someone who has been hospitalized, someone who had a serious bout with COVID," Khanna said. 

"Almost all of us now, as Americans, have had a real experience with the health care system about something very serious, and now almost everyone knows someone who's lost their job, or maybe lost their insurance...."

"Because I think there is a greater shared understanding ... I think that's created the groundswell for support for Medicare for All that includes people who are in the professional class and may not have thought about it."

The big picture: Rising unemployment has caused a massive loss in health insurance, making Medicaid a lifeline for those in need. Democrats have used the experience of COVID-19 to rally support for expanding public health care. 

Rep. Khanna: COVID-19 could change the perception of public health care

"I think there is a greater shared understanding."

Health Care

Politics

Coronavirus

2020 election

After a record economic expansion, the coronavirus pandemic sent the U.S. economy into a recession as unemployment soared to staggering heights. The country now faces urgent questions about how much stimulus is needed for reeling consumers and businesses, and what a recovery might look like.

Economy & Business

As part of our What Matters 2020 series on the critical trends that will outlive this moment, Axios co-founders Jim VandeHei and Mike Allen discuss the soaring costs of the American health care system.

The Medicare for All debate is hiding the fact that health care costs keep going up

Watch Part 1 on misinformation and manipulation

Watch: As Medicare for All debate rages on, costs keep going up

What Matters 2020

Health care has become the framework that defines the broader ideological and stylistic divisions within the Democratic primary — a contest between political revolution and Medicare for All vs. bipartisan compromise and a public option.

Yes, but:  It's kind of a false choice. Passing either of those health care plans would require a knock-down, drag-out party-line brawl just as intense as the fight over the Affordable Care Act.

Why it matters: No single issue has highlighted the differences among the Democratic candidates more efficiently — or more often — than health care, and Medicare for All, specifically.

It’s more than simple policy differences; in some cases, the policies aren’t even all that different. It has, instead, become a core extension of each candidate’s bigger political identity — whether they wanted it to or not.

Bernie Sanders and Joe Biden have already clashed over Medicare for All vs. a public option that Biden brands as "building on Obamacare," and that surely will continue after Biden's strong showing last night.

Ultimately, though, any Democratic president would run into many of the same brick walls trying to get any of these health care plans passed.

The health care industry, led by hospitals, has already poured millions of dollars into ads in key primary states opposing not only Medicare for All, but also a public option and even the narrowest proposals to let some people buy into Medicare.

Industry managed to kill a public option in the Affordable Care Act, when Democrats had 60 Senate seats. If they have a majority in 2021, it’ll likely be razor-thin.

My thought bubble: Democrats' health care plans have so far mattered a lot as a prism through which the candidates and their supporters have expressed big-picture principles and their theories of change. 

But these are not the same battle lines that would guide any real effort to significantly expand government-run health insurance.

What Biden's big Super Tuesday means for health care

Illustration of a Democratic donkey logo wearing a medical mask and stethoscope 

Data: Kaiser Family Foundation Tracking Poll; Note: ±3 percentage points margin of error; Chart: Andrew Witherspoon/Axios

Even many supporters of Medicare for All don’t necessarily know how it would work.

The big picture: That doesn’t necessarily mean more information will turn supporters into opponents, but it shows that we’re still at an early stage in this debate, in which opinions about Medicare for All are often reflections of broader political alliances, not the details of a plan.

By the numbers: In our January tracking poll, more than half (59%) of Medicare for All supporters didn’t think Medicare for All would require people to give up their employer-based insurance; 34% knew it would.

Democrats have learned more about the plan over the course of the party’s primary — 41% now know that people with employer coverage couldn’t keep it, up from 25% in June.

The big picture: People's opinions are still malleable.

Majority support for Medicare for All flips to majority opposition — 58% — if people think it would eliminate private coverage. And opposition rises to 70% if people think Medicare for All would lead to delays in care.

But support rises to 67% if people hear that Medicare for All would eliminate premiums and deductibles, and to 71% if they hear it would "make health care a right."

My thought bubble: Campaigns and the media are heavily invested in these differences among Democrats’ competing health care plans, but the public’s flexible opinions and lack of knowledge are a reminder that a lot of this is about signaling priorities, rather than adherence to a specific plan.

Even supporters may not understand Medicare for All

People's opinions are still subject to change.

Democrats finally debated health care subjects other than Medicare for All on Tuesday night.

Why it matters: We have a much wider range of health care problems than political debates usually suggest. Discussing rural Americans' lack of access to health care may not be as exciting as debating whether to do away with private insurance, but it's a subject that many voters struggle with every day.

And as the coronavirus is revealing, administrations don't always get to control what dominates their agenda.

What happened: The candidates were asked how they'd handle issues like rural health care and the coronavirus.

Amy Klobuchar talked about building up the health care workforce in rural areas, while Bernie Sanders talked up his role in increasing funding for community health centers through the Affordable Care Act.

Joe Biden talked about his experience dealing with Ebola and criticized Trump for cutting funding for the CDC.

Go deeper: Health care's imminent existential crises

Democratic health care debate topics finally expand past Medicare for All

The candidates were asked how they'd handle issues like rural health care.

2020 Democratic debate stage in South Carolina

2020 Democratic debates

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Data: Kaiser Family Foundation; Chart: Axios Visuals

Republican voters have moved on from the Affordable Care Act, shifting their focus and opposition instead toward Medicare for All.

By the numbers: In our latest Kaiser Family Foundation tracking poll, 19% of registered Republicans said opposition to Medicare for All is their top health care issue, compared to just 3% who said the same for opposition to the ACA.

Republicans’ top issue overall is the same as the overall public’s: Reducing health care costs.

Repealing the ACA was Republicans' top health care priority as recently as 2016.

Yes, but: This does not mean attempts to repeal the ACA are over. 

President Trump and many Republican leaders still support it, and the idea remains popular with Republican voters even as it has become a lower priority for them.

Between the lines: The ACA “s popularity is at a high point — 55% support and 37% oppose it — and many of its provisions are popular across partisan lines. 

The health care law was in some ways an outlet for Republicans to channel their broader opposition to Obama, so temperatures have cooled since he left office. 

And the least popular element of the ACA, the individual mandate penalty, is also gone. 

Repealing “Obamacare” will still generate applause lines at Republican rallies, but Republicans and President Trump now see a bigger payoff with their base from branding Democratic ideas as socialism and and attacking Medicare for All.

What’s next: If Sen. Bernie Sanders is the Democratic nominee, the focus on Medicare for All and the ensuing partisan warfare on health will intensify. 

If President Trump wins reelection, the current conflagration over Medicare for All will likely give way to a renewed debate about his plans for the ACA and Medicaid.  

Republican voters have moved on from hating the ACA

Only 3% of GOP voters say ACA repeal is their top priority.

Unions across the country are at odds over Medicare for All, with some saying it would free them up to focus on wages and working conditions, while others argue that the health benefits they've already won are better, Politico reports.

The big picture: The fight reflects the larger battle over Medicare for All, but is particularly acute in union-heavy states like California, New York and Michigan. This has all come to a head in Nevada, after the Culinary Workers Union slammed Medicare for All and didn't endorse any of the candidates, providing a portrait of how divisive the issue is within one of the Democratic party's most loyal institutions.

Go deeper ... Medicare for All: Where the Democratic candidates stand

Medicare for All is dividing unions across the country

It reflects the larger battle over the issue within the Democratic Party.

Photo: Bill Clark/CQ Roll Call via Getty Images

Reproduced from Kaiser Family Foundation; Chart: Axios Visuals

Health care was voters’ top issue in both Iowa and New Hampshire, and it benefitted Sen. Bernie Sanders as well as his more moderate rivals.

The  big picture: Sanders has emerged as a national front-runner thanks in part to a base that’s deeply committed to his Medicare for All plan, even as polling data indicate that more moderate ideas like a public option have a broader base of support.

By  the numbers: 37% of voters in the New  Hampshire exit poll said health care was their top  issue, placing it ahead of climate change, income inequality or foreign policy. Results were similar in Iowa entrance polls.

A majority (61%) of New  Hampshire primary voters supported both a public option and a Sanders-style single-payer plan.

Just 6% support only  single-payer, and not a public option, according to a Kaiser  Family Foundation analysis of AP VoteCast data, while 26% support a more moderate plan  but not single-payer.

“Single-payer  or bust” voters overwhelmingly supported Sanders, while  the “public option or bust” group was split among Pete Buttigieg (35%), Amy Klobuchar (34%) and Joe Biden (12%).

My  thought bubble: The hardcore single-payer fans are a  small group, even among Democrats. 

It’s big enough to win in  a crowded primary, but the broader — albeit divided — support for a more moderate plan may be a signal about the general election.

Yes, but:  Even among those Democratic voters in New Hampshire who said health care was the most important issue, more said it’s very important to have a candidate who can beat President Trump (89%) than one who has the best policy ideas (60%).

What Iowa and New Hampshire tell us about Medicare for All

Supporters are a smaller group, but they're less fractured.

Data: The Urban Institute; Note: 2020 estimates assumes all reforms fully phased in and in equilibrium, "Household spending" is for those 64 and under; Chart: Andrew Witherspoon/Axios

Democrats aren't debating small differences in health policy — a public option would be radically different than a shift to a single payer system, and a new analysis by the Urban Institute and the Commonwealth Fund illustrates just how big those differences are. 

By the numbers:  A public option — even a robust one — would cost the federal government an additional $1.5 trillion over 10 years. Full-blown single payer would result in a federal spending increase of $34 trillion. 

Yes, but: More federal spending doesn't necessarily mean the health care system as a whole is getting more expensive. 

Details: The analysis doesn't look at any specific piece of legislation or any particular Democratic candidate's plan, but it covers the spectrum of what's been proposed. 

National cost savings generally come at the expense of providers, as their payment rates would be regulated under expanded government coverage.

Democrats' health care plans by the numbers

Medicare for All is very different from a public option

Forget the Affordable Care Act: The future of our health care system will be shaped by a much bigger and broader fight — one that will likely culminate with a 2020 choice between private markets and an authentic government-run program in the form of a Bernie Sanders-style Medicare for All. 

The bottom line: The cost of health care — both for individuals seeking coverage and the government seeking sustainability — promises to return as the biggest domestic issue once the Trump obsession burns off. 

This is one of America's great unsolved problems: We have the world's best care, talent and innovation. But before it gets to patients, the magic goes through a hodgepodge of inexplicable, expensive and unnecessary hurdles.

What's next: The health care debate is no longer a linear fight over a straight repeal of President Obama's health care law. Instead, it has metastasized into a multi-front war.

One of our most vital national systems is falling apart:

Medicare is running out of money faster than expected — a reminder that no one's dealing with that problem, and that there's no way to duck it in 2020. 

The opioids crisis continues, with Congress trying to pass a ton of mini-bills to look like it's doing something. A few of them might make a difference. This remains a crisis — and a costly one. 

And don't forget prices. The U.S. doesn’t use more health care than other countries — we just pay more for it. Consumers are getting sick of it, and eventually they’ll respond to politicians with plans that seek to bring down prices (as they already have on prescription drugs).

Polls show health care is at the top of the list of voters' concerns for the midterms. So look for it to dominate the early rounds of 2020.

The new battlegrounds, as sketched by Axios managing editor David Nather:

The ACA repeal fight has moved to the courts, and the Trump administration has picked a fight over preexisting conditions — one of the most popular parts of the law.

But Republicans haven't given up on repeal. A group of outside conservatives is about to unveil a new plan and push congressional Republicans to take one more vote before November's midterms — even though there's no sign that any votes have changed.

"There's going to be at least one more grassroots effort to convince them to take another run at health care" so base voters don't think Republicans have given up, said Lanhee Chen of Stanford, a former Mitt Romney adviser who's part of the group.

Democrats have moved on to Medicare for All. The fight to watch will be between establishment Democrats, who want to make it voluntary and preserve a role for employment-based private insurance, and Democrats from the Sanders wing who are ready to move everyone into a government-run system.

"Democrats have always felt that health care should be a right," and they've watched the ACA actually become more popular under attack, said Neera Tanden, a former Hillary Clinton adviser who heads the Center for American Progress.

ACA premiums are going up, and for the first time it's Democrats who will try to turn that into a campaign weapon.

But health care spending and premiums are rising for everyone else, too.

By the numbers: Where America's health care spending goes

Why the U.S. never got universal health care

Health care is top voter priority in 2018

Republicans' next war: Pre-existing conditions

The new drugs and therapies keeping us alive longer

Deep Dive: The next health care wars

The health care debate is no longer a linear fight

This shows symbols commonly associated with health care

Deep Dive - Health Care

Every fight over the Affordable Care Act is a reminder of the bigger truth about the U.S. health care system: It's really a patchwork, not a system, because we never decided what our priorities were. Here's a look at how it developed and why it's not the kind of health care safety net other countries have.

All Medicare for All stories