When Bill Clinton became president, his top legislative priority was health care. When Barack Obama became president, he first had to prevent a depression, but then he too turned to health care.
The next Democratic president should choose a different priority.
It’s still true that too many Americans suffer from inadequate or expensive insurance coverage, and the next president should certainly look to make progress on health care. But presidents must make choices. Realistically, they have to pick one or two sweeping bills to try to push through Congress in their first year.
To argue that health care should be atop the list, you can’t simply say that it is important. You need to believe that it’s so much more important than everything else – climate change, voting rights, immigration, education, wage stagnation, the unfair tax system – that health care deserves to be the Democrats’ only top priority over four decades of presidencies. All those other issues would once again take a back seat.
And that would be a mistake because the both moral and political case for some other issues is now stronger than it is for health care.
Climate change threatens the well-being of the planet and everyone who lives on it. The next president can save more lives and better improve human health by slowing climate change than by improving health insurance.
The wounded state of American democracy is also more pressing. If it doesn’t get fixed, any expansion of health insurance could be reversed in a few years anyway. If the political system can be shored up – by guaranteeing voting rights, regulating campaign donations and granting statehood to Washington, D.C., and potentially Puerto Rico, among other things – every other national problem will become easier to address.
Unfortunately, these other issues are getting pushed to the margins in the 2020 campaign, while media attention has focused obsessively on Medicare. At every one of the six debates so far, Medicare has taken up a big chunk of the first half-hour, when the viewing audience is typically largest. In total, the candidates have spent almost 100 minutes talking about the subject onstage, more than they’ve spent on climate change, voting rights and tax policy combined.
The good news is that some of the candidates are also frustrated by the Medicare preoccupation, based on conversations I’ve had. At a campaign stop in Iowa last week, Elizabeth Warren resorted to asking reporters if any of them wanted to ask her about education. (She could have added: Research suggests that expanding pre-K and college may do more to improve people’s health than expanding health insurance.)
Obama’s presidency shows why the choice of priorities matters so much. He rightly insisted to his aides that they not only combat the financial crisis, but also try to pass major bills on both health care and the climate. Between the two, something had to go at the front of the legislative line, and Obama picked health care.
Partly as a result, the administration ran out of time on climate. The Senate moved slowly on health care – it’s a complicated subject, as you may have heard – and by the time senators were ready to take up a climate bill, the 2010 midterms were looming. Several senators weren’t willing to take another politically risky vote.
Health care became Obama’s signature accomplishment, extending coverage to some 20 million Americans. Climate was arguably his biggest disappointment. More than a decade later, with seas rising and severe storms causing more destruction, the country can’t afford to overlook climate policy again.
The next president can reasonably expect to have time for two big early priorities (barring another financial crisis). Even without health care – and even if the Democrats retake the Senate, a precondition for almost any ambitious bill – the decision would not be easy.
Michael Linden, who runs the Groundwork Collaborative, a Washington group that advocates for a fairer economy, has a suggestion that seems right to me: One priority should be democratic reform, like voting rights. The other should be a major economic bill that increases taxes on the wealthy and spends the money helping the middle-class and poor and promoting economic growth.
This second bill would include funding for clean energy, as well as limits on pollution. Depending on the politics, it might make sense to call the bill a Green New Deal.
Regardless, the bill should be organized around more tangible, immediate benefits than either the Obama or Clinton health care plan was. Remember, the politics of health care can be miserable. Most voters are insured, and they often focus on what they might lose from a new law. That’s a big reason Democrats fared so poorly in both Obama’s and Clinton’s first midterm elections.
What should the next president do on health care? Start by looking for concrete ways to expand insurance access and reduce costs, through narrower legislation or executive action. Many of these ideas – on prescription drugs, for example – are enormously popular, polls show. A radical transformation, on the other hand, is not.
Popularity isn’t everything, of course, and I understand why the next president may still want to go for radical transformation. It just doesn’t deserve to go at the front of the line. Health care should not be the only area where Democratic presidents are willing to spend political capital.
David Leonhardt is a columnist for The New York Times.