Cary Blum Op-Ed

Cary Blum, Contributing Editor

This week’s Republican presidential debate provided ample entertainment for politics-as-reality-TV junkies who thrive on one-liners, interruptions, and eye-rolls.  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 Americans—healthcare.

Lucky for me, that wasn’t something a quick internet search couldn’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, here’s what I did find.

Donald Trump doesn’t have a health plan on his website. But don’t worry, the Donald has “something terrific” up his sleeve. When pressed to describe his plan on a 60 Minutes interview, Trump reassured voters that he will “take care of everyone” by using government money to “make a deal with hospitals” 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.  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 Cruz’s site doesn’t broach healthcare, but perhaps the lack of a delineated platform can be excused.  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 Cruz’s “Health Care Choice Act” qualifies as one of the American public’s favorite types of bills: those that will never pass and serve only to waste Congress’ time. Second, this bill is not a plan. It begins by calling for a repeal of the ACA’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.  Upon visiting his website, I was relieved to find an explanation for the “replace” part of the oft-repeated “repeal and replace” mantra.  However, it was disappointing to see a plan concocted by a physician that limits access to healthcare.  In short, Carson would repeal the ACA (gulp!), raise the Medicare age to 70 and create so-called Health Empowerment Accounts (HEA’s). HEA’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, that’s because the model he is describing, the Health Savings Account (HSA), has existed since 2003.  One feature of Carson’s Health Empowerment Accounts that sets them apart from HSA’s (aside from the extra dose of empowerment, of course) is that immigrants—even legal ones—would be excluded. How patriotic!

Marco Rubio has a plan—one he proudly announced in an op-ed in Politico this August. Although Rubio’s plan is the meatiest, it’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.  First, he creates tax credits for healthcare spending which are reminiscent of the ACA’s subsidies, except that Rubio’s tax credits would be implemented gradually, in order to “prevent large scale disruptions.”  It’s funny that a candidate who vows to repeal the ACA in one fell swoop—a move that would abruptly cause thousands to lose insurance—is so concerned with large-scale disruptions.  Second, Rubio’s plan places patients with pre-existing conditions into “actuarially-sound high-risk insurance pools.” This move seems to mimic the ACA’s protections of patients with pre-existing conditions, but sadly, these high-risk pools are figments of Rubio’s imagination.  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 candidates’ healthcare platforms revealed little of value. Trump is walking back from his progressive stance because it doesn’t match his base. Cruz doesn’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.  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 don’t get much choice about the ACA—all four candidates want to dispose of it.

As I embark on the same voyage for the other nine candidates, I’m feeling pessimistic.  However, if the first four are any indication, I think it’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.