Ben Franklin may have been wiser than he knew. When he declared in 1789 that the only certainties in life were death and taxes, did he foresee that both would still be at the center of America’s politics 230 years hence, in the guise of our seemingly interminable debate over healthcare reform?

Healthcare was a dominant theme in the six Democratic presidential debates staged from June through December, and it’s a fair bet that it will continue to play a central role throughout the coming presidential election year. The reason is obvious: The issue touches everyone, regardless of race, creed, color or wealth.

The variations among the plans proposed by candidates Bernie Sanders, Elizabeth Warren, Joe Biden and Kamala Harris (who has since dropped out of the race) have been almost infinite and the proposals themselves, perhaps with the exception of Sander’s, fluid. Pundits have punished candidates for sticking with their initial proposals, or for backing off or doubling down.


Bernie Sanders, left, and Elizabeth Warren, right, listen as former Vice President Joe Biden speaks during the Democratic presidential primary debate in Houston on Sept. 12. (Associated Press)

Was Warren’s recent slide in opinion polls due to her original plan, or to her acknowledgment, via a “transition” proposal, that even under the most favorable political conditions, the U.S. won’t be changing from its private insurance system to single-payer in the blink of an eye, but only over a period of years? Who can say? (In her proposal, Warren said she would reverse President Trump’s “sabotage of healthcare” while making Medicare free for children younger than 18 and low-income households, on the way to making government health coverage free to everyone by the end of her first term.)

The proposals have all revolved around a nebulous idea known as “Medicare for all.” To the extent that the candidates have faltered in their approaches, it’s because they’ve tried to define Medicare for all. At this stage, however, that’s impossible. Whatever reform program ultimately emerges, it will be the product of intense legislative compromise, with the input of myriad stakeholders — doctors, hospitals, drug companies, wheelchair makers, insurers and patient advocates.


A screenshot of the Medicare website’s Plan Finder, which aims to make choosing a health plan easier.

Consequently, it’s best to think of Medicare for all as a binder holding the points that all the Democratic proposals share in common: universal coverage, the reduction or elimination of out-of-pocket costs such as deductibles and co-pays, the replacement of those costs and premiums with taxes and less spending overall.

How costs will be wrung out of the system and out of whose hide — caps on doctor fees? On hospital billing? On drug prices? — are impossible to pinpoint today. The more detail any candidates try to offer, the more they’re providing attack points for their adversaries.


What’s most important is that they recognize that there’s one real obstacle to crafting a fair, universal healthcare system like the ones enjoyed by residents of France, Germany and Britain, or even to preserving the reforms brought about through the Affordable Care Act. That’s Republican and conservative opposition.

Trump has tried systematically to erode the consumer protections created by the ACA, including safeguarding access to coverage for people with preexisting medical conditions and guaranteeing that health insurance plans provide for a roll of “essential benefits,” including maternity care, hospital coverage, prescription drugs and mental health and substance abuse treatment.

The Trump administration has taken steps to undercut that standard by expanding the availability of short-term health plans, which are cheaper than traditional Obamacare plans but don’t offer the full range of benefits and can reject applicants with preexisting conditions.


President Trump signs a Medicare executive order at the Sharon L. Morse Performing Arts Center in The Villages, Fla., on Oct. 3. (AFP via Getty Images)

The most serious threat to the ACA comes from a lawsuit brought by Texas and 19 other red states seeking to overturn the law, on the grounds that Congress’ elimination of the individual mandate penalty as part of the 2017 tax cut rendered the law unconstitutional.

The conservative U.S. 5th Circuit Court of Appeals in New Orleans could hand down a ruling on that claim any day now. Legal experts say the court could uphold the ACA, invalidate it in its entirety, or nullify it in only the 20 plaintiff states.


If the judges choose the last option, America would have a two-tier health system — one for 20 red states, another for California and other blue states. Whatever the outcome, the case seems destined to land at the U.S. Supreme Court, which has upheld the ACA twice, with arguments possibly scheduled just around the time of the November elections. As Franklin seemingly foretold, the healthcare debate will be with us well into the next year, and possibly beyond.