The debate that never ends: Washington’s constant health care fight

The president was barely a year into his administration when a health care debate began to consume Washington.

On Capitol Hill, partisan divides formed as many Democrats pressed for guaranteed insurance coverage for a broader swath of Americans while Republicans, buttressed by medical industry lobbying, warned about cost and a slide into communism.

The year was 1945, and the new Democratic president, Harry Truman, tried and failed to persuade Congress to enact a comprehensive national health care program, a defeat Truman described as the disappointment of his presidency that “troubled me the most.” Since then, 13 presidents have struggled with the same basic questions about the government’s role in health care, where spending now makes up nearly 18% of the U.S. economy.

The fraught politics of health care are on display again this month as millions of Americans face a steep rise in costs after the Republican-controlled Congress allowed Affordable Care Act subsidies to expire.

While the subsidies represent just one costly slice of the broader health care puzzle, their expiration has reopened long-festering grievances in Washington over health care management and the legacy of the ACA, Barack Obama’s signature legislative achievement that passed in 2010 without a single Republican vote.

“That’s the key thing that I’ve got to convince my colleagues to understand who hate Obamacare,” said Sen. Bernie Moreno, R-Ohio, who’s leading a bipartisan group of lawmakers discussing ways to extend some of the subsidies. “Let’s take two years to actually deliver for the American people truly affordable health care.”

Democrats have heard such promises before and argue Republicans have had 15 years to offer a viable alternative. They believe the current proposals being discussed, which largely focus on allowing Americans to funnel money to health savings accounts, fail to address the fundamental cost challenges of health care.

“They’ve had a lot of time,” said Rep. Steny Hoyer, the Maryland Democrat who was House majority leader during the ACA debate and recently announced he won’t seek reelection after serving since 1981.

The health care debate’s often-tortured dynamics have remained remarkably consistent. Obamacare dramatically expanded coverage but remains—even in the minds of those who crafted the law—imperfect and more expensive than many would prefer. Meanwhile, Washington appears more entrenched in stalemate than moving toward solutions.

“People hate the status quo, but they’re not too thrilled with change,” Rahm Emanuel reflected on the health care debate he witnessed as a top aide to President Bill Clinton, chief of staff to Obama, and Chicago mayor. “That’s the riddle to the politics of health care.”

Major reforms inevitably collide with a health industry—spanning pharmaceutical companies, health services, hospitals, and nursing homes—that spent more than $653 million on lobbying last year alone, according to OpenSecrets, which tracks political spending.

“Any time you try to figure out how to bring costs down, somebody thinks, ‘Uh oh, I’m about to get less,'” Hoyer noted.

When Obamacare was initially passed, public opinion was mixed, though KFF polling showed views tended to be more positive than negative. The law has since grown steadily in popularity, with a KFF poll from September 2025 finding about two-thirds of Americans now view the ACA favorably.

This shift has placed former President Trump and Republicans in a political bind. Since the ACA’s passage, Republicans largely dedicated themselves to the law’s destruction. Trump began calling for its repeal as early as 2011 and spoke in generalities during each presidential campaign about delivering better coverage at lower cost. During his 2024 debate against Democratic rival Kamala Harris, he referred only to “concepts of a plan.”

Under mounting pressure to offer specifics, Trump recently outlined what he called “The Great Healthcare Plan.” Rather than repealing the ACA, his proposal focuses on lowering drug prices and providing options for Americans to fund health savings accounts, bypassing the federal government to manage their own insurance. Democrats have dismissed this approach as insufficient to cover the high costs of health care.

Throughout his second term, Trump has criticized Obamacare for unfairly subsidizing insurers—an issue that could have been addressed had the original legislation created a public option to compete alongside private insurers. At the time, Republicans and many Democrats objected to that approach, arguing it would give government an outsized role in health care.

In a reminder that old policy debates never truly die, a small group of Democrats is now attempting to revive the public option discussion. Senators Sheldon Whitehouse of Rhode Island and Elissa Slotkin of Michigan, along with Representative Jan Schakowsky of Illinois, recently introduced legislation to create a public health insurance option on the ACA exchanges, though prospects in a Republican-controlled Congress remain dim.

Last year, a record 24 million people enrolled in ACA plans, though fewer appear to be signing up this year as the expired subsidies make coverage more expensive. The Supreme Court has upheld the law, and Republicans have failed to repeal, replace, or significantly alter it dozens of times. In the most famous instance, Senator John McCain cast the deciding vote in 2018 to preserve the legislation, noting there was “no replacement to actually reform our health care system and deliver affordable, quality health care to our citizens.”

Democrats successfully used Republican repeal efforts as a rallying cry in the 2018 midterms and see an opportunity to do so again with the expired subsidies. Senator Thom Tillis, R-N.C., who isn’t seeking reelection, has warned this moment could be even more politically perilous for Republicans.

“Us failing to put something else in place did not create this cliff,” Tillis said. “That’s the fundamental difference in an election year.”

Even architects of the ACA acknowledge the system’s imperfections. Former Senator Max Baucus, a Montana Democrat who helped craft the bill as chair of the finance committee, conceded that “nothing is perfect,” particularly regarding high health care costs.

“Bending the cost curve, that has not bent as much as we’d like,” he said.

Some Republicans have expressed openness to a deal on subsidies, viewing it not as an endorsement of the ACA but as a bridge allowing time to address more complex issues. “We need to get to a long-term solution,” said Rep. Don Bacon, R-Neb.

Veterans of past health care negotiations remain skeptical that lawmakers can produce meaningful reform without the type of in-depth negotiations that preceded the ACA. “It takes a long time to figure all this out,” Baucus cautioned.

When asked whether he’s studied that history as he begins health care talks, Senator Moreno, in office for only a year, was blunt: “I don’t know s—. What that means is I don’t have scars.”