The Democratic presidential candidates have been fighting over whether they should try to replace the health insurance system with a single government-run plan or create a government-run plan that Americans could choose to join.
But hidden outside this big debate is a harsh reality: If Democrats fail to retake control of the Senate, neither plan has much of a chance to become law.
Elizabeth Warren, the Massachusetts senator, has allied herself with the “Medicare for all” wing of the party, saying she would propose a single-payer system. But on Friday, she released a second plan, a sort of steppingstone along the way that would create a more optional government program. Her transition plan is engineered to pass with only a majority of Senate votes, instead of the 60 usually needed to overcome a filibuster.
But it also includes a long and detailed list of the things she would do if she couldn’t get Congress on board. That section of the report, which is likely to get less attention and draw less criticism than the rest, actually tells us a lot about what health care policy would probably be like in a Warren administration.
President Trump was elected in part on a promise to transform the health care system. His efforts to repeal and replace the Affordable Care Act have been unsuccessful, as Republicans in the Senate are unable to agree on any one solution.
But he has used his regulatory authority to make many of the changes he was unable to achieve through Congress, like expanding the availability of insurance plans that cover fewer benefits; reducing federal funding of Planned Parenthood; permitting states to establish work requirements for Medicaid benefits; and increasing the size of special accounts that workers can use to save money for health care expenses.
He has also pursued other regulatory projects in health care, like his proposal, finalized on Friday, that would require hospitals to publicize the prices they have negotiated with insurance companies. He is allowing states to import drugs from Canada through regulatory power, and aiming to overhaul care for patients with renal disease.
So what would Warren do? Her regulatory agenda can be divided into a few broad categories. But over all, she views executive authority in the same broad way that Trump does. Several of her proposals are likely to end up in court — as several of his have.
Here are the big areas where she has regulatory ideas.
Reverse Trump administration policies
One big chunk of her plan would reverse some Obamacare regulations established by the Trump administration. She would return funding to Planned Parenthood and other reproductive health groups that also offer abortion services, for example. She would restore funding to publicize insurance options. She would eliminate new requirements on Medicaid beneficiaries, such as work requirements and premiums. And she would change rules to restrict the sale of so-called short-term health plans, which don’t follow all the Affordable Care Act’s rules.
She would restore an Obama-administration policy that provided civil rights protections to transgender patients and women with a history of abortions, among other groups.
Expand benefits in existing insurance programs
She would seek to offer subsidies to new groups of people to help them buy health insurance under Obamacare, including legal noncitizen immigrants and the families of people who can obtain coverage for only themselves through work.
She would also seek to add a dental benefit to the Medicare program, by reinterpreting language in the statute that says dental care can be covered only if it is “medically necessary.” And she would change aspects of the Medicaid program, making it easier for states to offer coverage to more people, even if it will cost the government more.
She would write new rules for a 2008 law that requires insurers to cover mental health care in the same way they cover care for physical ailments. The goal is to expand coverage for mental illness and substance abuse across different types of insurance.
Lower drug prices
Ms. Warren’s regulatory agenda is perhaps most aggressive in its efforts to limit drug prices. She proposes that the federal government employ never-before-used authority to rescind existing patents on medications that were developed with the help of government funding. She would also expand an infrequently used authority so that the government itself could manufacture certain drugs in public health emergencies. Among the drugs and devices she would target are insulin, EpiPens, antibiotics and medications for hepatitis C, H.I.V. and opioid overdoses.
The list of policies above does not include everything that Ms. Warren has proposed. She’d also like to beef up antitrust enforcement in health care, for example. But it gives a sense of the breadth of things she would try to do in health care, even without Congress’s help.
President Trump is far from alone in failing to enact his preferred health policies through legislation. Several presidents before him have struggled to pass major health overhauls. As Democrats head into another debate next week, the moderators may want to consider asking candidates what’s on their health care regulatory wish lists. The answer may be far more useful in predicting the shape of their policy agenda than the details of their legislative dreams.