The government shutdown is over, and Democrats have failed to obtain an extension of subsidies for plans under the Affordable Care Act. That means premiums will skyrocket for the tens of millions of Americans who get their insurance through the ACA marketplaces. While Democrats look for other ways to save the subsidies, though, the party also needs to lay the groundwork for a bigger fix to America’s broken health care system.
It’s been a decade and a half since President Barack Obama signed the ACA into law, which in turn came a decade and a half after Bill Clinton’s failed attempt at health care reform early in his presidency. For the last 15 years, Democrats have said the same thing about the Affordable Care Act: The law has done a tremendous amount of good, but it’s far from perfect. Despite the ACA’s successes, our health care system is still a failure in multiple ways, and only one party wants to fix it. The time is now to start planning for the next phase.
Every Democratic president in the 80 years since Truman made at least some attempt to move toward universal coverage and containing costs.
In 1945, President Harry Truman proposed that the federal government provide health insurance to all. “Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health,” he said. “Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and that protection.”
That time, in fact, kept arriving; every Democratic president in the 80 years since Truman made at least some attempt to move toward universal coverage and containing costs. There were successes along the way, including Medicare, Medicaid and the ACA itself. But most Americans are unhappy with the U.S. health care system as a whole, even if many are happy with their own insurance.
Although health care is typically one of the party’s strongest issues, Democrats have largely been on the defensive since the ACA was passed in 2010. They’ve worked hard, mostly with success, to beat back Republican attempts to repeal or undermine it. This has been a necessary and noble effort: Since the ACA’s passage, the share of Americans without health insurance has been cut in half, from 16% to 8%. But 27 million Americans are still without coverage. That number is expected to increase dramatically, both because of the expiration of enhanced subsidies and because Trump’s “big, beautiful bill” includes massive Medicaid cuts and restricts access to ACA marketplaces.
That means Democrats have no choice but to come up with a new plan they can present to the public for health reform — and it has to be more than just reinforcing the ACA.
This will require both policy work and political advocacy, which was exactly what the party did after Clinton’s reform failed. Health policy experts spent years researching and developing ideas, and by the time the 2008 election arrived, the party had coalesced around an outline of what would become the ACA — a combination of subsidies for people in the middle to buy insurance, an expansion of Medicaid and a mandate for everyone to get covered. While Obama, Hillary Clinton and John Edwards argued about the details in that year’s presidential primary, their differences were minor because they were working from a policy consensus that had already taken shape.
Twelve years later, there was another intense debate over health care in a Democratic presidential primary. And though it seemed in 2020 that there was a gulf between the ideas from progressives, such as Sen. Bernie Sanders’ proposal for a single-payer system, and those from the more moderate candidates, including Joe Biden, in truth the whole party had moved left. Even Biden’s plan, which centered on a public option, was far more progressive than the ACA.
Opponents of health care reforms count on Americans believing that we can’t have anything better.
But once he took office, Biden essentially put that plan in a drawer and never spoke of it again. You can argue that he wouldn’t have been able to pass it through a closely divided Congress, but he never tried to build the support that would have made it possible.
So what should Democrats do now? The answer is that they should spend the next couple of years debating it among themselves. Task the policy experts with devising a menu of options, talk to voters, begin advocacy for real reform and see where support builds. Then, when 2028 comes, have the debate during the presidential campaign when the largest number of Americans are paying attention.
My own preference would be to model our next reform on the combination of public and private insurance that’s used successfully in various forms in countries such as Australia, Canada, France and Denmark. In this system, the government provides basic insurance that covers everyone, and people are free to buy supplementary private insurance if they want more benefits. Liberals like it because of the universal coverage, and conservatives like it because rich people can still buy all the benefits they want. We could get there by expanding Medicaid — which already covers more than 77 million Americans — to everyone under 65, while allowing seniors to keep Medicare. Yes, there would be many details to work out. And powerful forces will array themselves against meaningful reform — not just the GOP, but the many people, organizations and companies that benefit handsomely from the current system. Opponents of health care reforms count on Americans believing that we can’t have anything better, or at the very least that it can only be a little bit better. But we know that isn’t true, because every other industrialized country on Earth has a national system that is far less expensive than ours, yet still insures all or virtually all residents. Last weekend, President Donald Trump proposed sending money to Americans instead of to insurance companies. He later said that people will “feel like entrepreneurs” when they’re “able to go out and negotiate their own health insurance.” It’s an incoherent and nonsensical idea that will only make health care expensive. But Republican lawmakers quickly signaled support, with Sen. Rick Scott of Florida saying he was “writing the bill right now.” Unlike their opponents, Democrats need to be serious about health care. And that means finding the next big proposal to get closer to a system that all Americans can actually count on and afford. It won’t be an easy process, and it won’t be quick. But that makes it all the more important to start now.
Paul Waldman is a journalist and author whose writing has appeared in dozens of publications. He writes The Cross Section, a newsletter about politics and culture, and hosts the podcast of the same name. His latest book is "White Rural Rage: The Threat to American Democracy." 
