WASHINGTON -- With the Affordable Care Act now secure in the framework of the nation's health care programs, Democrats are eager to leap above and beyond.
They want to expand insurance coverage for working-age people and their families, add new benefits to Medicare for older people and reduce prescription drug costs for patients and taxpayers.
But health care is expensive, there's concern about deficits and with Democrats holding only bare majorities in Congress, a winnowing down of expectations seems likely later this year.
For now, Democrats are savoring Thursday's Supreme Court decision upholding "Obamacare" for the third time in a decade. The latest challenge to the law had been seen as a stretch by many legal experts, but a 7-2 vote from the conservative court was unexpected.
"I think Democrats once again know they have a moment in time, and they want to make the most of it," said Kathleen Sebelius, health secretary under President Barack Obama during the passage and implementation of the health law. "I think people are fired up and ready to go."
There is no shortage of proposals. Some, such as authorizing Medicare to negotiate prescription drug prices, could potentially save hundreds of billions of dollars, depending on how they are structured. But coverage and benefit expansions could cost an equal or even much greater amount.
Complex budget procedures that Democrats plan to use to pass President Joe Biden's domestic agenda by a simple majority vote in the Senate may also limit the types of proposals that can be considered.
"There is a sorting going on," said John McDonough, who was a senior Democratic aide in the Senate during the debate over the health law. "Not all of these ideas are viable, but you don't always know which ones at the start." McDonough is now a professor at the Harvard T.H. Chan School of Public Health.
Democrats' ideas fall under two big headings: expanding coverage and benefits through public programs such as Medicare and the Obama law, and using the power of government to rein in the price of prescription drugs. In theory, savings from prescription drugs can pay for program expansions without adding to the deficit or raising taxes.
"These are not proposals in the single-digit billions," said Marc Goldwein, senior policy director with the Committee for a Responsible Federal Budget. "We're talking $100 billion, $200 billion or more -- but in different directions. The more they save, the more they can spend." His group advocates for reducing federal deficits, and Goldwein adds that "it's my hope they abide by the basic rule that you pay for what you're willing to spend."
Early on, a hierarchy of proposals has started to emerge.
At the top of the list, and most likely to be included, is Biden's plan to permanently extend more generous HealthCare.gov insurance subsidies. They're now provided through the end of next year under his COVID-19 relief bill. The price tag is estimated at $163 billion over 10 years.
Another health law issue involves figuring out how to cover more than 2 million low-income people in mainly Southern states that have not expanded their Medicaid programs. A federal fix is not just a matter of pumping more money in because of arcane legal issues involving Medicaid.