Imagine this: What if President Trump's thoughtless and malicious attack on the American health-care system wound up leading to something more efficient and humane than what we have now — even something like single-payer health coverage? As odd as that sounds, it could happen, because of the way that in contemporary politics we careen from action to reaction.
We'll get to the politics in a moment, but to begin one must understand that right now, the Trump administration is working to sabotage the Affordable Care Act, which in practice means attempting to send the individual health insurance market into a "death spiral" of rapidly decreasing enrollment and increasing premiums. While it might make sense for them to decide that since they're in charge of the government they should try to make things work — if nothing else then to avoid the political fallout that will come from the fact that they bear responsibility for implementing the law whether they like it or not — they have decided to do nothing of the sort.
Open enrollment, when people select their health plans, starts on Nov. 1. But this year it will be half as long as it used to be, only six weeks, thanks to a Trump administration decision. In addition, the White House has slashed the advertising budget for outreach encouraging people to enroll by 90 percent, slashed the budget for "navigators" that help people through what can be a complicated process, pulled out of events promoting enrollment, and even created videos whose purpose is to discourage — yes, discourage — people from getting insured. And their repeated threats to cut off cost-sharing payments that allow people with low and moderate incomes to get care have already produced higher premiums, as insurers are gripped by uncertainty about what is to come.
The goal behind all these moves is very simple: Minimize the number of people who sign up. But since those who desperately need insurance — those who are sick, older, or have pre-existing conditions — will be much more likely to overcome the burdens and enroll, it will be the younger and healthier who don't get around to it or give up trying. This means that the pool will be full of more expensive patients, which will send premiums rising, which will drive more younger and healthier people out, which will increase premiums, and so on. That's the death spiral.
So what happens if they succeed? The first thing is that people will suffer. Insurance will become less affordable, and many will go without it, leading to economic catastrophe if they have an unexpected illness or accident (one of the extraordinary and largely unreported successes of the ACA was that between 2010 and 2016, the rate of personal bankruptcies in America was cut in half, thanks to more people having insurance and the law's outlawing of annual and lifetime limits on coverage).
With that suffering, and rising premiums and deductibles, will come demands for change.
Republicans will say, "Don't blame us, ObamaCare is failing." President Trump has been clear all along that this is his plan. "I think we're probably in that position where we'll just let ObamaCare fail," he said in July. "We're not going to own it. I'm not going to own it. I can tell you the Republicans are not going to own it." But that's not how it works. Even if voters aren't familiar with the ways the administration is sabotaging the ACA, voters blame the party in power when things go wrong.
Which gives Democrats an opening, one they have to seize by proposing fixes specifically geared to the problems the Trump administration is either creating or exacerbating. Fortunately for them, if they want to move toward a system of true universal coverage — which is the direction their party is going — there are easy-to-understand fixes they can propose.
The simplest would be to let people buy into Medicaid. If you don't like the options on the marketplaces where you are — because there are too few insurers, or because deductibles are too high, or for whatever other reason — you should be able to take advantage of the same program that many of your neighbors enjoy, and which has become extremely popular. In the short term, that would give people a secure and reasonably affordable option, solving the problems that the Trump administration has created. In the longer term, it could bring us closer to the day when Medicaid becomes a default basic health plan for all Americans who want it. If the current debate has proven anything, it's that the public is perfectly fine with the idea of getting health coverage through the government.
Democrats don't have the ability to enact any reforms yet, but they should start building support now. That way, if they're to take back Congress and the White House by 2020, they'll have specific ideas in place that they would have already sold to a public ready to see the problems in the health-care system addressed.
Above all, Democrats should understand that health-care reform is a very long game, one that has many stages. Success at each stage requires policy and political preparation. You can dream about the fantastic system you'd like to see, but getting there will require not one but a series of victories, none of them easy to achieve. The Trump administration has created an opening for their next victory, but they'll have to take advantage of it.