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Why Democrats didn't talk more about health care at their convention

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Health care policy got remarkably little discussion during the Democratic National Convention in Philadelphia, despite repeated nods to the issue from Hillary Clinton, Barack Obama, and Bernie Sanders. Here's why.

No one wanted to talk about the costs, regulations, and other tough tradeoffs that would be involved in further expanding insurance coverage under the Affordable Care Act, improving affordability for consumers, curbing medical spending growth, and reducing prescription drug costs.

Democratic presidential nominee Ms. Clinton's ambitious health care proposals surely will require new revenues and involve pain for powerful stakeholder groups. Those requested new revenues would come on top of new money needed for her other expensive initiatives including infrastructure investment, more generous Social Security benefits, free college, and expanded child care.

And all that would have to win approval from a Congress that may still be at least partly controlled next year by Republicans who want to repeal the ACA and who firmly oppose most new taxes. The Democrats haven't figured out how they would get around that little problem.

Surprisingly, no one last week even mentioned the Republicans' highly unpopular proposal to convert Medicare into a defined-contribution, voucher-type system, which would potentially expose seniors to higher out-of-pocket costs. It's too early, said Tom Lopach, executive director of the Democratic Senatorial Campaign Committee. Wait until after Labor Day, when voters are paying full attention, for the Democrats to unleash their attack ads on that issue, he added.

Another reason Democratic leaders and strategists weren't talking health care is that they were primarily focused on making sure Ms. Clinton beats GOP nominee Donald Trump in November. So their main job last week was uniting the party after the emotionally charged primary battle between Ms. Clinton and Sen. Bernie Sanders.

There's broad agreement among Democratic health policy experts that a Trump victory, combined with continued GOP control of Congress, would lead to a major rollback of President Obama's historic achievement in moving the country toward universal health care. The Republicans would use the budget reconciliation process, which requires only a simple Senate majority, to repeal the ACA's premium subsidies and Medicaid expansion, said Ron Pollack, executive director of Families USA, a pro-ACA advocacy group, during the convention week's only health policy forum last Wednesday.

“It would be a crazy different world,” said Chris Jennings, an outside health policy adviser to the Clinton campaign.

And not far beneath the surface, there are lingering differences between the Clinton and Sanders wings of the Democratic Party over how to improve affordability and access under the ACA, despite an official deal on the party's health policy platform. Under pressure from Sen. Sanders, Ms. Clinton and the party strengthened their support for adding a public plan option to the ACA exchanges and allowing people 55 and older to voluntarily buy into Medicare. Sen. Sanders approvingly cited Ms. Clinton's health policy positions in his speech endorsing her last Monday.

But some Democratic-leaning health policy experts question whether the public option and the Medicare buy-in can win passage in Congress, and whether those measures would be effective in improving affordability and access without hurting the private insurance market. Much of the health care industry is likely to fight hard against the public option.

Mr. Pollack said a Ms. Clinton victory would “open space for dialogue” on incremental improvements in the ACA. But he and the other panelists, including former Senate Majority Leader Tom Daschle, avoided talking about potential bigger deals between the Clinton administration and congressional Republicans, such as offering states much greater flexibility on Medicaid in exchange for GOP support on ACA expansion.

Asked whether he really expected Ms. Clinton, if she's elected, to follow through on the public option and Medicaid buy-in proposals, Sen. Sanders' 2016 presidential campaign manager Jeff Weaver told Modern Healthcare, “We'll hold her feet to the fire.” If she backed off, that likely would cause major recriminations from the left wing of the party.

During the Wednesday panel discussion, Democratic strategists stressed the need to make healthcare more affordable, noting that rising out-of-pocket costs were a major factor behind the popularity of Sanders' single-payer health insurance proposal. “Affordability is the key issue,” said Neera Tanden, executive director of the liberal Center for American Progress and a former senior aide to Clinton. “We have to have a broad conversation with the whole country about health care costs.” She and former Sen. Majority Leader Tom Daschle agreed on the importance of shifting from fee for service to value-based payment models such as bundling.

But Ms. Clinton herself mainly talks about increasing subsidies, such as giving insured people a $5,000 per family refundable tax credit for out-of-pocket costs exceeding 5% of income and capping out-of-pocket costs for prescription drugs. She also has promised to sharply expand funding for federally qualified community health centers. “If you believe that every man, woman, and child in America has the right to affordable health care, join us,” she said in her acceptance speech Thursday.

That was as detailed as she got on health policy. She didn't mention any of the less politically popular measures many experts believe are needed to bend the cost curve, such as narrower provider networks, reduced coverage for medically unproven services, more restricted drug formularies, tighter management of benefits, and stronger incentives for healthy behaviors. These are uncomfortable issues, and a close presidential election contest is not the time when most politicians want to bring them up.

Ms. Clinton's health care proposals likely would cost billions of dollars. When asked how those new expenditures — along with new spending to improve the nation's infrastructure and expand Social Security and child care — would square with mounting pressure to control growing federal spending growth on entitlements and reduce government debt, several members of a separate panel of Democratic strategists convened by Politico Magazine last week had a simple answer. Clinton should raise taxes on rich people and corporations, said Lee Saunders, president of American Federation of State, County and Municipal Employees, AFL-CIO. Mr. Weaver, the Sanders campaign manager who also was on the panel, seconded that.

In her speech that night, Clinton agreed with them. “We're not only going to make all these investments, we're going to pay for every single one of them,” she said. “And here's how: Wall Street, corporations, and the super-rich are going to start paying their fair share of taxes.”

To do that, the Democrats will have to win back both the Senate and the House. Without the money, it's hard to see how a President Clinton could fulfill her health care promises.

Harris Meyer writes for Modern Healthcare, a sister publication of Business Insurance.