Democrats' health care ambitions meet the reality of divided government

In her first speech as speaker of the House, Nancy Pelosi made it clear that she knows that health care is key to why voters sent Democrats to Congress.

"In the past two years the American people have spoken," Pelosi told members of Congress and their families who were gathered Thursday in the House chamber for the opening day of the session. "Tens of thousands of public events were held, hundreds of thousands of people turned out, millions of calls were made, countless families, even sick little children — our little lobbyists, our little lobbyists — bravely came forward to tell their stories and they made a big difference," said Pelosi, a California Democrat.

What is the Democrats' mandate?

"To lower health care costs and prescription drug prices and protect people with pre-existing medical conditions," she said to applause.

In their campaigns last year, Democrats promised to protect the Affordable Care Act, and the access to coverage that it guarantees for many people. Many Democrats went further, running on the promise of "Medicare-for-all."

But now that Democrats control the House, their ambitions are meeting up with reality.

With the Senate in Republican hands and President Trump having promised to repeal the ACA, Democrats' ability to make sweeping health policy changes is limited.

Instead, they'll likely rely on hearings and turn to the courts to try to influence health policy and shore up the ACA.

Pelosi started on Day 1.

Just hours after her speech, House Democrats voted to intervene in a lawsuit in an effort to protect the Affordable Care Act. The House will join several state attorneys general in appealing the ruling of a federal district judge in Texas that the law is unconstitutional. And Rep. Frank Pallone, D-N.J., head of the Energy and Commerce Committee, announced a hearing on the impact of the ruling. He said he intends to hold lots of hearings to review the Trump administration's actions around the ACA — actions he calls "sabotage."

"At a time when the Trump administration is doing all the sabotage of the ACA, I think the focus really has to be on trying to prevent the sabotage and making sure the ACA is strengthened," he said in an interview in his Capitol Hill office.

That "sabotage" includes Trump's decision to stop reimbursing insurance companies for discounts they're required by law to give to their lowest-income clients, Pallone said. He also cited a Department of Health and Human Services rule change that allows insurance policies that don't carry the full benefits required by the ACA to be renewed for up to three years. In the past, those plans were intended to serve as a bridge for someone between jobs and were limited to just a few months

Pallone said these and other changes may violate the law.

"I think if you do some good oversight and find out what the sabotage consists of, then you can say, 'Well this isn't allowed under the law,' " Pallone said. "And then you either take it to court or try to get legislation passed."

Oversight is a powerful tool, said Chiquita Brooks-LaSure, a former HHS official who is now a managing director at Manatt Health Strategies, a consulting firm.

"I don't think we should underestimate how important that is, when decisions that are being made are questioned and officials have to defend them," she said.

For the past two years, the focus in Washington has been on repealing or dismantling the Affordable Care Act. That's about to change, she said.

"That energy can now shift to examining what the administration is doing and putting forth other ideas and other proposals, some of which might generate bipartisan agreement," she said.

Pallone is hopeful that Republicans may support some measure to shore up the ACA. In the last Congress, Sen. Lamar Alexander, R-Tenn., proposed bills that would restore those payments to insurers, and he backed a plan to create a reinsurance program that could help reduce premiums.

Pallone acknowledged Democrats' plans are much less ambitious than the "Medicare-for-all" proposals that many of his colleagues touted during their campaigns.

"I just think it's unlikely that we could ever pass it," he said. "So I don't want to prioritize that." Copyright 2019 NPR. To see more, visit https://www.npr.org.

Correction (2019-01-10 05:00:00 UTC):

An earlier Web version of this story mischaracterized Manatt Health Strategies as a lobbying firm. It is a consulting firm.