In the wake of Republicans failing to repeal and replace Obamacare and the Democratic takeover of the House, where will the health care debate go from here?

No important health care legislation will come out of this gridlocked Congress. But the run-up to the 2020 presidential campaign will produce at least a Democratic health care plan out of the nominating process.

People 65 and older accounted for over one third of U.S. medical spending. Yet despite the fact that government pays for 65% of the elderly’s medical expenses, the burden of health spending (out-of-pocket expenses as a percentage of income) is much higher among the elderly than among those below age 65. You might suppose that a policymaker in 2008 would look at these data and conclude that if there is a crisis in affordability within the U.S. population, it lies among the elderly. 

Gallup polls have been asking some big picture questions about the major dimensions of health system performance–quality, coverage, costs and access–for nearly two decades now. This allows me to show you a long time series of trends that leave little doubt that despite many lofty promises made for Obamacare (or the high hopes of its proponents), Obamacare essentially left American health the same or worse on quality, coverage, costs and access . I found literally no evidence in these data that it made things better.

The Democratic party is moving steadily toward a full embrace of Medicare for All as its official health-care policy. While the term is flexible enough to mean different things to different people, the overall direction is clear enough. The party is advocating for the enrollment — eventually — of all Americans in a government-run insurance plan of some sort.

Last month, Judge Reed O’Connor of the U.S. District Court for the Northern District of Texas issued a ruling declaring Obamacare unconstitutional. The case was brought by 20 Republican state attorneys general. Seventeen Democratic state attorneys general responded January 3 by appealing to the U.S. Court of Appeals for the 5th Circuit.

Judge O’Connor appears to be on a bit of an island — the conventional wisdom on both the right and left is that his decision will be overturned by a higher court.

The number of uninsured Americans is rising. Last year, 27.4 million Americans went without health insurance, an increase of 700,000 from 2016, according to a just-published analysis from the Kaiser Family Foundation. Government mandates deserve much of the blame. Regulations and red tape have driven premiums through the roof, pricing many Americans out of the insurance market. Nearly half of uninsured people cite high premiums and prohibitive deductibles as the reasons they aren’t covered. Free-market reforms would enable millions more people to afford insurance that fits their needs and those of their family.

Numbers released this week by the government show just a slight dip in the number of people enrolled in Affordable Care Act coverage next year through HealthCare.gov. That’s the case even though the Republican-led Congress repealed fines for being uninsured effective Jan. 1. The drop — from 8.8 million to 8.5 million — was far less than experts forecast.

“The five hearings we held reminded us of something else we should agree on: one major reason for the unnecessarily high cost of health care is that the health care system does not operate with the discipline and cost saving benefits of a real market. Too many barriers to innovation drive up costs. And most Americans have no idea of the true price of the health care services they buy—which also drives up costs.”

—Sen. Lamar Alexander 

Please submit comments to LowerHealthCareCosts@help.senate.gov by March 1, 2019.

Rather than opting for the cheap, politically expedient trick of “blaming Big Pharma,” our national leadership should insist that all members of the health-care ecosystem create expert-vetted, user-friendly education programs so that patients know the real costs of what they’re buying, where the profits are going and, most importantly, how they can use this knowledge to become savvier consumers.

The U.S. labor market is as healthy as it has been in a long time, especially for those with limited education and skills. Yet enrollment for the nation’s two largest means-tested safety-net programs, Medicaid and the Supplemental Nutrition Assistance Program, remains near historic highs.

In previous periods of rising employment and income, takeup rates in assistance programs dropped. This hasn’t been the case in the years following the Great Recession, even after accounting for ObamaCare’s expansion of Medicaid. What gives?