An Unhealthy Republican Debate

Donald Trump was demolished in the 10th Republican presidential debate, but I’m not sure it will make any difference.

The problem is, the man who demolished him, Marco Rubio 2.0, was a newcomer to the debate stage—and the fact that we’d only seen the risk-averse Rubio 1.0 in the previous nine debates limited the feisty new guy’s credibility. His revised stance was obviously a political calculation in a year when the voters seem to be sick of political calculations.

Trump, by contrast, has been Trump right from the jump. He is authentically boorish and nasty. I’m not sure that you can suddenly transform yourself from grasshopper to gladiator and not seem a bit phony somehow, even though the Florida senator brought it off low-key, funny and well.

It is possible that Rubio’s assault on Trump will have the same effect as Chris Christie’s assault on Rubio: It may ding Donald a bit, but it may also have been a kamikaze mission, doing Rubio no good at all or even, perhaps, hurting him.

In my wildest moderate fantasy, the beneficiary of the combined Rubio-Cruz attack would redound to the benefit of John Kasich–who, yet again, established himself as the one candidate on the stage with both feet planted on Planet Earth. But that hasn’t happened in previous debates.

Aside from the central trash-Trump narrative, I found the discussion of Obamacare—and health care in general—to be weird and misleading, and typical of what passes for “substantive” discourse in these circuses. Let me take you into the weeds a bit:

Donald Trump is right about “the [state] lines” which limit the market for purchasing health insurance, but he doesn’t have a clue about anything else. Obamacare—and its conservative predecessor, the Heritage Foundation plan—depend on market principles. Individual state markets (the term of art is “health care exchanges,” which are websites—like Amazon or Travelocity—where purchasers can compare health insurance plans) are inefficient, and too many of them offer minimal choices. There was an effort to create larger, regional markets in the final stages of the Obamacare debate. For some obscure reason—it probably has to do with insurance company lobbying—the idea was killed by moderate Democrats. Part of the problem was that most Republicans were refusing to negotiate. They were simply against the bill; if they’d participated, we might have had a much more effective program.

Donald Trump is wrong about “the lines” being the most important thing. The most important thing is who pays for the people who work, but don’t make enough money to pay for health insurance? (Medicaid pays for the people who don’t work.) In a CBS News interview, Trump said bluntly: “The government’s gonna pay for it.” Well, that’s one way to do it. Another is to impose an “individual mandate”—that is, to require healthy young people who don’t think they need health insurance to buy some. The implicit deal is that young people have a moral and civil responsibility to pay into the system when they’re healthy so that the system will take care of them when they’re older and less healthy. The original Heritage plan, which John Kasich (wisely) supported in 1994 had a mandate.

Kasich is wrong about the individual mandate being unnecessary. If you want to cover less-healthy people—those with pre-existing conditions—everyone has to pay into the system. There are two ways to do this: by requiring people to buy in, or by the less efficient and more inequitable method of having the government pay for it. In the end, Obamacare needed both the mandate and government subsidies for the working poor—because it was loaded down with “gottas.” You gotta cover contraception. You gotta cover mental health. You gotta cover abortion. The original Heritage Found plan had none of these gottas, which make the program less comprehensive but cheaper. If Republicans had chosen to negotiate the Obamacare system, we might have ended up with something more like the one that Ben Carson was (unintelligibly) describing: health savings accounts—where the insured person can decide which coverage he or she wants—plus catastrophic coverage, in case something awful happens to you. This would, I believe, have been a good compromise.

Kasich was incomprehensible about what he’s doing about health care in Ohio, which he says would be a model for a national system if he wins the nomination. I suspect he’s trying to get rid of the current fee-for-service system, which encourages doctors to provide services (blood tests etc.) even when they’re not necessary. The alternative (used by the Cleveland Clinic) is to pay doctors salaries and, as Kasich said, give them performance bonuses based on how well their patients fared. This is one good way to control costs, and it is working well in private Medicare Advantage plans. But it is not very popular with patients.

Both Cruz and Rubio are screaming fire in a crowded theater when they describe Obamacare as “job-killing.” What they’re referring to is the supposition that thousands people will leave the workforce if they can get “free” health care. This may or may not be true at the margins. The overwhelming majority of people prefer to work. (It also presupposes that people will leave jobs that already provide health insurance, which—almost by definition—are better paying and more satisfying jobs than flipping burgers). On a sounder footing, they’re arguing that this will discourage small businesses, which are not required to provide healthcare, from growing larger and being required to cover them. This is called an “employer mandate,” and it is, surely, a bad idea. The “individual mandate” was posed as an alternative to that. Obamacare is a mixed system of individual and employer mandates. Once again, the absence of Republicans in the Obamacare negotiations caused this mess—and Republicans could, surely, help clean it up if they were willing to play. (The fact that they haven’t been willing to play is disgraceful.)

The bottom line is that Obamacare is not a disaster, but it could have been—and could still be—made better if the Republicans had decided to negotiate a more efficient system. The original Heritage Foundation plan had the advantage of being intellectually honest; it covered everyone, it limited the deductibility of health insurance for wealthier people, but it assumed that individuals could decide the type of health care they wanted. I still think it’s a good idea.

But it’s not the sort of thing one can debate rationally in 2016.