Cary Blum, Contributing Editor
This weekâ€™s Republican presidential debate provided ample entertainment for politics-as-reality-TV junkies who thrive on one-liners, interruptions, and eye-rolls. Â It even offered a sliver of meaningful debate on topics like foreign policy. But given the nearly three-hour duration of the affair, there was strikingly little discussion of a topic important to many Americansâ€”healthcare.
Lucky for me, that wasnâ€™t something a quick internet search couldnâ€™t solve! So I visited the websites of the top four polling Republican candidates (Donald Trump, Ted Cruz, Ben Carson and Marco Rubio) to learn about their stances on healthcare reform. Voters will be upset to know that I found very little of substance. But for the record, hereâ€™s what I did find.
Donald Trump doesnâ€™t have a health plan on his website. But donâ€™t worry, the Donald has â€œsomething terrificâ€ up his sleeve. When pressed to describe his plan on a 60 Minutes interview, Trump reassured voters that he will â€œtake care of everyoneâ€ by using government money to â€œmake a deal with hospitalsâ€ that care for poor people, thereby achieving universal coverage. Despite his lack of a plan, at least Trump, unlike others, wants to get everyone covered. But he deserves no credit for reinventing the disproportionate share hospital (DSH) payment, a system Medicare has used for decades to reimburse hospitals that provide lots of charity care. Â Recently, with the passage of the Affordable Care Act (ACA, also known as Obamacare) the DSH payment program was downsized; it turns out reimbursements for charity care decrease when more people have insurance. Perhaps Trump should embrace his true ideology and again advocate for the single-payer system that he endorsed in his 2000 book, The America We Deserve.
Like Trump, Ted Cruzâ€™s site doesnâ€™t broach healthcare, but perhaps the lack of a delineated platform can be excused. Â After all, this March, Cruz introduced a bill purporting to be an alternative to the ACA. So his plan must be somewhere in this bill, right? Not so much. First, it must be noted that Cruzâ€™s â€œHealth Care Choice Actâ€ qualifies as one of the American publicâ€™s favorite types of bills: those that will never pass and serve only to waste Congressâ€™ time. Second, this bill is not a plan. It begins by calling for a repeal of the ACAâ€™s insurance mandates (surprise!) and adds a provision that allows insurance companies to sell plans across states lines. This second part is perhaps a decent idea, but by no means constitutes a plan.
Moving on to someone who should know a thing or two about healthcare: Ben Carson. Â Upon visiting his website, I was relieved to find an explanation for the â€œreplaceâ€ part of the oft-repeated â€œrepeal and replaceâ€ mantra. Â However, it was disappointing to see a plan concocted by a physician that limits access to healthcare. Â In short, Carson would repeal the ACA (gulp!), raise the Medicare age to 70 and create so-called Health Empowerment Accounts (HEAâ€™s). HEAâ€™s are tax-sheltered savings accounts assigned at birth along with social security numbers, which are paired with high-deductible insurance plans. If this sounds familiar, thatâ€™s because the model he is describing, the Health Savings Account (HSA), has existed since 2003. Â One feature of Carsonâ€™s Health Empowerment Accounts that sets them apart from HSAâ€™s (aside from the extra dose of empowerment, of course) is that immigrantsâ€”even legal onesâ€”would be excluded. How patriotic!
Marco Rubio has a planâ€”one he proudly announced in an op-ed in Politico this August. Although Rubioâ€™s plan is the meatiest, itâ€™s also the most flawed, both in its hypocrisy and its ignorance. Rubio takes the revolutionary move of repealing the ACA (gasp!), and then recreates three parts of the law in defective or opposite versions of themselves. Â First, he creates tax credits for healthcare spending which are reminiscent of the ACAâ€™s subsidies, except that Rubioâ€™s tax credits would be implemented gradually, in order to â€œprevent large scale disruptions.â€ Â Itâ€™s funny that a candidate who vows to repeal the ACA in one fell swoopâ€”a move that would abruptly cause thousands to lose insuranceâ€”is so concerned with large-scale disruptions. Â Second, Rubioâ€™s plan places patients with pre-existing conditions into â€œactuarially-sound high-risk insurance pools.â€ This move seems to mimic the ACAâ€™s protections of patients with pre-existing conditions, but sadly, these high-risk pools are figments of Rubioâ€™s imagination. Â Attempts at creating such high-risk insurance markets have failed time and time again due to a phenomenon called adverse selection. Last but not least, as opposed to expanding Medicaid a-la-ACA, Rubio limits the program by transforming federal contributions to a per-capita block grant.
In the end, my journey through the top four GOP candidatesâ€™ healthcare platforms revealed little of value. Trump is walking back from his progressive stance because it doesnâ€™t match his base. Cruz doesnâ€™t have any thoughts about health policy other than hating Obamacare. Carson creates something that sounds downright empowering, but is just a limited version of an existing program. And Rubio proposes a bizarro-Obamacare that is missing a modicum of sense. Â All in all, voters get to choose between no policy at all, existing-but-ineffective policy, and policy that has been proven to fail. But they donâ€™t get much choice about the ACAâ€”all four candidates want to dispose of it.
As I embark on the same voyage for the other nine candidates, Iâ€™m feeling pessimistic. Â However, if the first four are any indication, I think itâ€™ll be a quick trip.
Cary Blum is a dual degree MD/MPA student in his fifth and final year at NYU. He is specializing in healthcare policy at Wagner and is currently applying for residency programs in internal medicine.