Henry Waxman and George Miller spent their congressional careers advocating for reforms. POLITICO Pro Health care torch passed … to nobody Next generation of Dems less visionary, more wonky.

Henry Waxman and George Miller spent nearly 40 years pushing universal health care. John Dingell — who helped pass the Medicare law in 1965 — fought for a vision of health care coverage for all Americans as far back as the Kennedy administration.

They’re all leaving Congress at the end of this month.


Who will be the new health care leaders for Democrats? Sens. Chris Murphy of Connecticut and Ben Cardin of Maryland want more delivery system reforms. Sen. Patty Murray of Washington wants better contraceptive coverage and more doctors. All three want to beef up mental health coverage. And Sen. Ron Wyden of Oregon and Rep. Frank Pallone of New Jersey aren’t even saying what’s on their agenda — they want the Republicans to go first. It’s all smaller bore stuff — a real comedown from the visions of the past.

The generational upheaval leaves the national health care debate in flux as a new Republican Congress takes control in January. There are no clear grand plans that can break the cycle of Obamacare fights, but the lack of big Democratic ideas — and defenders — leaves the health care law open to change. In fact, one of the most eagerly awaited proposals is actually coming from Republicans — a replacement for Obamacare that’s being developed by two possible GOP presidential candidates: Paul Ryan, who’s about to become the new House Ways and Means Committee chairman, and Sen. Marco Rubio of Florida. Rubio has described it, but neither one will say when it’s going to be released.

( Also on POLITICO: Massive spending bill kicks off 113th Congress’ final chapter)

Some Democrats hope that the changing of the guard — occurring as the health care law is starting to run more smoothly — means there will be more chances to move on, and even focus on health care issues that don’t automatically put both parties at each other’s throats.

“Health care has been in lockdown for the last four years,” said Murphy, who took a leading role in pro-Obamacare messaging this year and may become a more prominent health care voice in the next Congress. “My hope is that the health care debate will loosen up as the ACA settles in.”

The Republicans, meanwhile, are losing Dave Camp, the House Ways and Means Committee chairman from Michigan who played a major role in the GOP’s pushback against Obamacare. And Montana Democrat Max Baucus, the former Senate Finance Committee chairman who had a big hand in the writing of the law, left earlier this year to become ambassador to China.

The turnover is bringing new Democrats and Republicans into positions of power — with vastly different ambitions on where to go next.

Murray, who is expected to become the top Democrat on the Senate Health, Education, Labor, and Pensions Committee, is likely to keep fighting to restore the law’s contraception coverage requirement, which was scaled back by the Supreme Court. But she’s also focusing on ways to build on the law, such as finding more ways to increase the supply of doctors. Murphy, another member of the HELP Committee, would like to see more of an emphasis on making the delivery of medical care more efficient, building on experiments in the Affordable Care Act that aren’t particularly controversial. Cardin, a member of the Finance Committee, is in the same mode.

And all three want to improve mental health care, an area where they see at least some potential for common ground with Republicans. “We’re not going to get a background check bill anytime soon,” said Murphy, referring to proposals for tougher scrutiny of anyone who tries to buy a gun. But “I do think there are some Republicans who are willing to at least reorder the way we send mental health care dollars to the states” to emphasize early intervention, he said.

So far, though, there’s no sign of a mass movement among Democrats to rethink the basics of the law, even though it was clearly not a help to them in the midterm elections.

Even Wyden, the current Senate Finance Committee chairman who will become the ranking Democrat next year, is reining in his habit of pursuing independent solutions on the law, such as letting states opt out of the law’s major provisions if they can provide the same health coverage in other ways. He’s being extra careful not to part ways with other Democrats again, saying nothing about his agenda for next year other than that Republicans have to make the first moves and that “the Affordable Care Act is here to stay.”

There’s some openness to tweaks, especially on issues like repealing the medical device tax and getting rid of the law’s definition of full-time work as 30 hours a week. Cardin acknowledged that “we’re still trying to find the sweet spot on definitions,” as long as any tweaks don’t undermine the goal of expanding health coverage. But just as often, Democrats who are moving into positions of power are focused on expanding parts of the law — like Murray, who wants to continue an expiring Medicaid pay increase for physicians.

The main agitators for change are a group of red- and purple-state Democrats, including Heidi Heitkamp of North Dakota, Joe Manchin of West Virginia and Mark Warner of Virginia, who want to add features like low-cost “copper” health care plans and exempt more businesses from the employer mandate. But they’re about to become a smaller group: They’re going to lose Mary Landrieu of Louisiana, who lost her seat in a runoff election Saturday, and Mark Begich of Alaska, who was defeated in November.

The big issue, though, is what to do now that Democrats are about to lose their majority in the Senate. Some of them want to press ahead with the “fixes” plan even though the Republicans will be in charge next year. “I’m always for the repairs,” said Manchin. “I’m hopeful that we can get together and do something in a bipartisan way, put points on the board.”

But there doesn’t seem to be a lot of enthusiasm for that among Democrats who are moving into leadership roles. “I do think it’s necessary for [the law] to have an opportunity to play out for a while before you talk about any changes,” said Pallone, who’s about to replace Waxman, a retiring longtime Democratic lawmaker, as the top Democrat on the House Energy and Commerce Committee.

Even Sen. Claire McCaskill of Missouri, a red-state Democrat who’s not shy about criticizing her party, says the next move is up to Republicans, not Democrats. “I’m an eternal optimist. I believe the Republicans meant it when they said they had a plan to fix the ACA. I’m waiting with bated breath to see that plan,” she said, her voice dripping with sarcasm.

And the reality is that “fixing” the health care law isn’t likely to be in the cards, given where the movement is on the Republican side.

The most influential Republicans are likely to be the ones who can spell out Obamacare replacement plans, not just shout “repeal” every chance they get. Even if the law isn’t really going away anytime soon, there will be more of a demand for the GOP to detail the kind of health care system they’d prefer, and to show how more choices and fewer mandates would actually solve problems without hurting the most vulnerable patients.

That demand is likely to raise the profiles of Sens. Orrin Hatch of Utah, who’s expected to become the next Finance Committee chairman, and Richard Burr of North Carolina, who have outlined an Obamacare alternative with retiring Sen. Tom Coburn of Oklahoma. Their plan — which would have to be turned into detailed legislation — would give people tax credits to buy whatever kind of health insurance they want if they don’t get coverage through a large employer.

It’s also going to put a new spotlight on Ryan, who, as the new Ways and Means chairman, will have more power to push detailed legislation than he did as Budget Committee chairman. That includes the rewrite of Medicare that drew so much fire from Democrats when he was writing House GOP budgets. But he’ll also have the authority, if he chooses, to push for a vote on his Obamacare alternative with Rubio.

“Ways and Means is 100 times more powerful” than the Budget Committee, said Tom Scully, who was administrator of the Centers for Medicare & Medicaid Services under President George W. Bush. “I think Paul Ryan would tell you the same thing, otherwise he would have stayed at Budget.”

The way Rubio described the emerging alternative on a talk-radio show in October, it would give people a greater variety of choices of health care plans — because “a healthy, single, 25-year-old male needs different health insurance than a married father of four” — and tax credits to help pay for them. He also hinted that it would allow insurance companies to sell across state lines, a standard feature of most GOP health care proposals. “We want to have every American be able to buy the kind of health insurance they want, at a price they’re willing to pay, and from any company in America that will sell it to you,” he said.

All of these plans would face tough questions about how they’d deal with pre-existing conditions — one of the biggest problems addressed by Obamacare — and what they’d do about the millions of people who have already enrolled.

Ryan says he’ll keep pushing to repeal Obamacare and to overhaul Medicare, even though he knows neither will happen while President Barack Obama is still in office. But he won’t say whether he’ll put the Obamacare replacement bill up for a vote — and his aides aren’t saying whether he’ll write a complete bill based on his plans to turn Medicare into a system of limited insurance payments. But he’s staffing up in a big way, as if he expects to be a major center of gravity for the big policy fights next year, including health care.

Even though Republicans have every incentive to keep fighting Obama on health care, not all of the newly influential Republicans say that’s going to be their only mission.

Rep. Tom Cole of Oklahoma, an ally of House Speaker John Boehner, will gain a powerful subcommittee chairmanship next year: He’ll head the appropriations subcommittee that funds the Department of Health and Human Services and all of its programs, including the implementation of Obamacare. He’s no fan of the health care law, but he’s not threatening to cut off its money, either.

And he says there could even be “some things where we can find some common ground,” such as ending the law’s medical device tax and getting rid of the 30-hour workweek.

“I don’t think our general position has changed. … I’m a believer in free markets and patient choice,” Cole said. Still, he said, “I would hope that there would be a mixture of confrontation and hopefully cooperation.”