(Photo illustration by Bill Kuchman/The Bulwark | Photos: Getty, Shutterstock)
ONE REASON HEALTH CARE is such a good issue for the Democrats in this year’s midterms is that pretty much everybody from the party’s different factions agrees on the problem and the solution.
For the moment.
In the short term, the problem is that Donald Trump and the Republican party cut Medicaid, then refused to extend enhanced Affordable Care Act subsidies, putting health care at risk for tens of millions of Americans.
The solution is to undo the cuts and renew the subsidies, which is precisely what Democratic leaders say is at the top of their agenda for a hypothetical new Congress and—if Trump won’t go along—a hypothetical trifecta two years later.
But the American health care system had big problems even before Trump and the Republicans delivered those blows to Medicaid and “Obamacare.” Millions of people lacked insurance, though far fewer than before the Affordable Care Act, and millions more struggled with high premiums or out-of-pocket costs.
That’s why Democrats are talking about next steps for finally getting to truly universal coverage—which, in turn, has restarted old arguments about whether to seek a total health care sector reset with Medicare for All or to seek more incremental changes, some of which would still be highly ambitious and some of which would not.
That debate got a ton of attention in the primaries. And while it has subsided a bit since, because it’s now Democrats versus Republicans rather than Democrats against each other, it is sure to kick up as soon as the midterms are over.
One person who has been thinking a lot about that debate is Andy Kim, the Democratic junior senator from New Jersey. He’s already got an idea for how the party should move forward if it gets the chance to legislate: He wants to act quickly to guarantee health insurance to all children as a first step toward bigger and more comprehensive reforms, through a proposal he calls “MediKids.”
It sounds intuitively simple, which is a bit deceptive once you get into the policy weeds. The thirteen-page bill Kim and three cosponsors introduced in July comes with all kinds of unanswered questions and, if implemented, would force all kinds of tradeoffs. Those include possible effects on existing private insurance and, naturally, the fiscal impact.
But those things would be true of any major health care proposal, as they would be for sticking with the status quo. And MediKids has plenty going for it, including the potential to keep the party united and to build some momentum for bigger changes, all while helping a bunch of children get health care they desperately need.
As Kim made clear to me in an interview—which you can watch below—that’s not a bad sales pitch.
KIM, WHO HAS BEEN IN CONGRESS for less than ten years and in the Senate for less than two, is not especially well known either to the public at large or inside the wonky world of health policy. But he sits on the Health, Education, Labor and Pensions Committee. And health care has played a key role in his political career, which started in 2017 when the newly elected Trump and the Republican Congress set out to repeal the Affordable Care Act.
At the time, Kim’s wife was pregnant with their second child, whom doctors had determined was seriously underweight and at risk of severe health problems, and possibly not surviving at all. “The doctors came in and talked to us, and they said, ‘You know, there’s a problem,’ which is the last thing you want to hear when you’re there for an ultrasound,” Kim told me.
“It was devastating to get this news,” Kim went on to say, “and while I’m there taking my wife to the hospital constantly for different therapies, to see what we can do to get the weight up, I was watching the TV and I was watching the news, and my own congressman from New Jersey is leading the charge on trying to gut pre-existing condition protections.”
Kim was referring to Tom MacArthur, a House Republican whose deal with GOP leaders, hatched quietly when it appeared negotiations had broken down, got legislation through the House and over to the Senate. Repeal never got through the upper chamber, stopped there by the dramatic thumbs-down vote of Arizona Republican John McCain. But Kim ran for Congress, making a defense of the Affordable Care Act and its protections for people with pre-existing conditions the centerpiece of his campaign.
Kim’s victory was part of the 2018 blue wave, in which the backlash to repeal played a major part. Since then he has continued to talk about health care reform and developed a special interest in children’s coverage—very much because, he told me, he’s a young father who understands what’s at stake.
“Thankfully my baby was born, we’ve been able to manage his health challenges, now he’s an all-star on his soccer team, and I’m really proud of that,” Kim said. “But ever since then, it really just stuck with me—the concerns about health care for everybody, but in particular when it comes to kids, when it comes to those who are most vulnerable, those who can’t look out for themselves, those that we as adults have a responsibility for.”
Kim, a Rhodes Scholar, also made it his business to learn about policy and the history of reform—leading him to propose MediKids, which, among its other virtues, is relatively simple to explain. It would automatically enroll every newborn into a new insurance program, giving parents the chance to opt out if they have alternative coverage in place. Kids could then stay on the program until they are 26 years old.
Automatic enrollment, which would start two years after the law’s enactment, is the crucial element. Most children are eligible for some kind of insurance already, thanks to not just the Affordable Care Act but also to expansions of Medicaid and the Children’s Health Insurance Program, a 1997 reform. But because the patchwork of existing programs can be extraordinarily difficult to understand and navigate, kids fall through the cracks constantly, which can mean (among other things) that they miss out on screenings, checkups, and other preventive measures that keep them healthier later in life.
More children are bound to lose coverage in the future thanks to Trump and the Republicans: The “One Big Beautiful Bill” requires would-be beneficiaries to go through even more onerous enrollment processes—and pushes states to question eligibility a lot more aggressively. That’s one reason most analysts predict more children are about to become uninsured. Automatically enrolling children would prevent that kind of slippage from happening.
Kim emphasized to me that he does not see MediKids as a stopping point for reform, or an alternative to any of the more sweeping proposals that would seek to insure people 26 and older. On the contrary, he said, he imagines this as a chance for Democrats to move fast and deliver benefits quickly to a politically sympathetic group before turning their attention to more ambitious changes.
Critically, Kim said he believed that covering all children would create a public “expectation” of universal coverage that would create support for filling in the gaps at other ages—perhaps, again, through some kind of automatic enrollment.
“Are you really going to have this type of care,” Kim asked, “and then all of a sudden—when you’re [26] years old—want to give it up? I think it’s going to be something that’ll absolutely put us on that path for universal care.”
KIM IS BY NO MEANS the first politician to think of reaching universal coverage this way. Many of Medicare’s original champions, back in the 1960s, envisioned gradually expanding the program to cover people at different ages until eventually it covered everybody. Democrats in Congress and running for president in the early 2000s also proposed kids-first strategies.
In fact, two of them, former West Virginia Sen. Jay Rockefeller and former California Rep. Pete Stark, actually also called their proposal “MediKids.”
A distinguishing element of Kim’s proposal is that he wants to cover children through Medicaid, not Medicare. The reason is a sign that he’s thought about this proposal seriously. The benefit package for basic Medicare has large out-of-pocket costs (that’s why most people have some kind of supplemental coverage, or enroll in “Medicare Advantage” private plans, which fill in the biggest gaps).
Medicaid, by design, has virtually no out-of-pocket spending and comes with a much broader set of benefits, including coverage for services like testing for lead poisoning, which is especially critical for babies and children with developing brains vulnerable to damage from such toxins. “Over 23 million kids are underinsured, which means their coverage isn’t meeting their needs,” Kim said. “That’s absolutely an abomination, in my opinion.”
Kim said he was also trying to be practical, by trying to expand coverage “in a way that isn’t trying to create some brand new agency, department, bureaucracy.” But Medicaid has some well-known weaknesses, too. Among other things, it can be hard for beneficiaries to find specialists who will accept it, because it pays providers so little.
Kim says boosting those payments would be an essential part of any legislation. That would add to his program’s costs—as would the possibility that some employers would stop offering coverage to dependents, so that the public sector would effectively be absorbing some of the health care expenses that employers now bear.
“Democrats will be looking for ideas that could represent additional steppingstones to universal coverage, and kids are a sympathetic group and relatively inexpensive to insure,” Larry Levitt, executive vice president at the health policy research organization KFF, told me over email. But, he noted, “Providing universal coverage to a group like kids who in many cases already have private insurance raises thorny issues about what happens to the money employers are paying into the system now.”
Kim said he hadn’t gotten a Congressional Budget Office estimate yet, but said it’s important to keep in mind the program’s long-term benefits. “I think of health care for children in particular being really an investment in this country,” Kim said. “Healthier kids mean healthier adults, which means a healthier workforce, which means a more productive economy.”
THERE WAS A TIME, not so long ago, that insuring children was a bipartisan cause. But it’s hard to imagine many Republicans going for a plan of even modest cost, let alone one that offers coverage to undocumented immigrants, as MediKids would.
Kim said he crafted his plan with that in mind, figuring it could pass through the reconciliation process—in other words, with just a simple majority in the Senate, rather than the sixty votes it would take to overcome a filibuster. “This is not a messaging bill,” he said. But getting all the Democrats on board could present its own challenges.
In most states, private insurers run Medicaid plans under contract, making MediKids a potentially tougher sell with progressives who are reluctant to support expansions that build on any form of private coverage. And while Kim envisions passing MediKids as a quick, targeted action, there’s no guarantee it couldn’t bog down a new president and Congress as much as bigger reforms might, potentially squandering the chance to do more.
Those political questions are important for Democrats to consider, as are the policy and budgetary implications of MediKids. But with any real chances of enactment likely two years away, now is the perfect time for Kim to showcase his idea, and see how it holds up to scrutiny.