Yet the lack of a Democratic alternative also stems from a central disagreement about whether the ACA needs a legislative fix at all. Democrats have accused the Trump administration of sabotaging the law administratively by refusing to guarantee the payment of cost-sharing subsidies to insurers and by sending mixed signals about whether it would enforce the mandate that people buy insurance or pay a tax penalty. If the administration simply implemented the law as intended, they say, Congress could stand down. “There’s a very good chance that it’s sustainable if you just do those things,” said Representative John Yarmuth of Kentucky, the top Democrat on the House Budget Committee. Murray told me she “absolutely” believed the law could stand on its own if the Trump administration implemented it properly.
Other leaders in the party, however, suggested to me the law was not quite as stable. Insurers had been pulling out of the Obamacare exchanges before the November election, and while these Democrats do not agree with Republican characterizations that the law is “collapsing,” they argue that Congress needs to act at least to stabilize the individual market. “The individual market, if you’re not buying through an employer—even if you do get a subsidy—is pretty unstable,” Senator Tim Kaine of Virginia, the Democratic vice-presidential nominee last year, said in an interview. “I do think some legislative fixes would really send signals to the American public, as well as the stakeholders, that we’re serious about finding improvements.”
Kaine and Senator Tom Carper of Delaware on Wednesday introduced legislation to create a reinsurance program to help insurers offset the cost of covering older, less healthy customers. That type of program—which provides payments to insurers that enroll high-cost individuals—was originally part of Obamacare until it expired last year, and Republican legislators in Minnesota and Alaska have embraced the idea as a way to stabilize insurance markets in those states. “That’s something that should have some bipartisan appeal,” Kaine said.
The Democratic ideas fall roughly into two categories: proposals that might attract support from Republicans as part of a short-term fix if the repeal effort fails, and those that will only be viable if the party can retake one or both chambers of Congress in 2018. Murray’s renewed call for a public insurance option— which would compete with private insurance in the marketplace—almost certainly falls in the latter bucket. Democrats fell a few votes shy of including a public option in the 2010 law, but the idea faces staunch opposition from Republicans and insurance companies who see it as a slippery slope to a completely government-run health-care system.
A push to allow the government to negotiate lower drug prices for Medicare and Medicaid would likely run into a similar blockade. But the proposal has had an unlikely ally in President Trump, who earlier this year took meetings with Democrats and pharmaceutical companies after calling for increased competition to bring down prescription costs. Representative Frank Pallone of New Jersey, the top Democrat on the House Energy and Commerce Committee, said the cost of prescription drugs was the biggest complaint he’s heard from constituents about health care. Democrats, however, suspect Trump isn’t serious about confronting Republicans who have long opposed the idea of allowing the government to negotiate prices. “We’ve never heard from the president again on this issue,” said Representative David Cicilline of Rhode Island, a co-chairman of the party’s policy and communications committee.