As candidates talk past each other, real debate over health reform goes missing

No one expected health care to be AWOL on the campaign trail, and it hasn’t been. In January the Kaiser Family Foundation Tracking Poll found that the cost of health care and health insurance ranked only third in importance for all registered voters, behind terrorism and jobs, while the Affordable Care Act came in eighth. The problem is not lack of interest, I’d wager. It’s that campaign talk has been way too sketchy and uninformative, leaving voters with precious little to chew on. They’ve tuned out. So it’s fair to ask: What exactly are the candidates saying about their positions on this most contentious of issues?

To explore this, I turned to Theodore Marmor, Yale professor emeritus whose specialty is health politics. “Most American debates about health care reform have been dominated by ideological slogans, misleading claims about financing, and mystifying labels,” he argues, and this year is no different. “The result,” Marmor says, “is a dialogue of the deaf, with each side talking past the other and little or no engagement with realistic description of either worthy reform increments or longer-term reform aspirations.” That translates into an empty discussion about Obamacare’s shortcomings and how to fix them, the shape of the insurance system, and the high price of care, especially for prescription drugs, which shuts out the public from understanding and ultimately from having a say in what’s to be done.

Marmor is talking about the Democratic side of the ledger, and so far, he says the Dems’ debate has been both confusing and misleading, with Clinton’s discussion of short-term reforms largely ignoring the question of what the country’s long-term future should look like, and Sanders emphasizing policy prescriptions, in particular his vision of Medicare-for-all social insurance, without discussing incremental steps that might be needed to achieve his objective. What would each do to make health care less costly, less complex and more accessible to achieve their goal of universal coverage which both say they share? Instead, Clinton is telling voters what’s wrong with Sanders’ ideas, Marmor says, but not what’s right about her own. Sanders omits the political tactics needed to get from A to B on the road to “Medicare for all.”

"Most American debates about health care reform have been dominated by ideological slogans, misleading claims about financing, and mystifying labels. The result is a dialogue of the deaf, with each side talking past the other and little or no engagement with realistic description of either worthy reform increments or longer-term reform aspirations." — Theodore Marmor, Yale

Health expert Marilyn Moon, who now directs the Center for Aging at the American Institutes for Research, explained the missing element in Sanders’ stump talk. “While I have a lot of sympathy for single-payer, the way Sanders is selling it makes me grind my teeth,” she told me, noting that having single-payer doesn’t instantly translate into lower costs. “You have to do things to save money. He’s selling people a bill of goods and making them believe change will be painless.” That observation gets to the heart of the U.S. health care dilemma. To save money, bring down costs, and give everyone coverage, the country has to control payments to doctors, hospitals, and other providers, and limit the availability of services that don’t work and sometimes waste hundreds of thousands of dollars. That’s been the issue every time the country has grappled with health reform, including Obamacare. “This would require a lot of painful adjustments and Americans aren’t ready for that,” Moon believes.

Perhaps that’s why no candidate is showing leadership on that fundamental problem and helping to bring Americans along. In other words, they are not changing the discourse — the way we think about limitless health care and the consequences of paying whatever the market will bear, and whatever taxes are needed to cover everyone. It’s easier and safer to let the misleading claims, mystifying labels, and ideological slogans fly through the media and above that very real dilemma, which allows the public to pick and choose the claim, label, or slogan they are predisposed to accept.

The mid-February debate with Sanders and Clinton is a good example of what Marmor and Moon are talking about. Clinton told viewers that every progressive economist who has analyzed Sanders’ numbers says they “don’t add up and that’s a promise that cannot be kept. We should level with the American people about what we can do to make sure they get quality, affordable health care.” Clinton said she had “very specific plans about how to get costs down,” especially for prescription drugs, but instead of defining those plans, she again attacked Sanders’ “Medicare-for-all” program. “If it’s ‘Medicare for all,’ then you no longer have the Affordable Care Act, because the Affordable Care Act, as you know very well, is based on the insurance system, based on exchanges, based on a subsidy system,” implying that people would not longer get help paying Obamacare’s high premiums. “Many people will actually be worse off than they are now,” she said. Sanders didn’t explain how subsidies for low-income people would not be necessary under his plan, simply brushing off Clinton’s charge as “inaccurate.” Instead he used his time to talk about lower costs in France, Canada, and the UK. “We can guarantee health care to all people in a much more cost-effective way,” he concluded. No word on how he’d achieve this except to say that we can do it if we have the courage to take on the health care industry.

Clinton and Sanders do discuss their proposals more fully on their websites, though details are still sketchy — more blah-blah campaign talk. Sanders’ website gives few specifics about lowering costs, but he does say moving to an “integrated system” will give the government the “ability to stand up to drug companies and negotiate fair prices” and “track access to providers” and “make smart investments to avoid provider shortages.” To make premiums more affordable, Clinton says she wants to “enhance” subsidies for those now eligible to buy exchange policies. Regulating premiums, however, is not one of her remedies. Why not? Why are enhanced tax credits better and for whom?

Website visitors also learn that “Hillary believes we need to demand lower drug costs for hardworking families and seniors.” How will that work? Both Sanders and Clinton favor some Medicare negotiation for drugs, but as Julie Rovner points out in an insightful piece for Kaiser Health News, “The only way Medicare negotiation would save money is if the program decided to cover some drugs and not others,” which is what the Veterans Administration does. (Otherwise, Medicare is unlikely to be more successful in negotiating lower prices than private payers have been.) That, of course, gets into the dangerous territory of leadership and changing the health care conversation.

The Republican side of the ledger is easier to parse, but it, too, is filled with misleading claims, ideological slogans and mystifying labels. Donald Trump, Ted Cruz, and Marco Rubio have all declared Obamacare dead if they win the presidency. In his victory speech after the New Hampshire primary, Trump yelled to his cheering fans, “ We’re going to repeal and replace Obamacare. It’s a total disaster. It’s gone.” On his website Rubio says, “Obamacare has revealed the painful consequences of placing our faith in big government.” Cruz asserts on his that Obamacare “is the most unpopular law in the country.” 

The GOP’s menu of fixes after burying Obamacare is old hat, with scrutiny and questions as scarce as they are on the Democratic side. There’s been little or no serious discussion of whether those with low incomes can actually save with a health savings account. Nearly 90 percent of Obamacare policyholders last year needed subsidies in order to buy insurance. There’s been little discussion from the GOP of potential remedies to bring costs down, such as letting insurers sell across state lines. Insurers can do that now if a state allows them in and most do. Will tax credits to help people buy coverage really help the 29 million Americans who don’t have it now, as the GOP suggests?

If the public is looking for leadership to change the country’s health insurance arrangements and cover everyone at a lower cost, so far they haven’t gotten it. But can the discussion really happen given how dumbed-down the media discourse has become? Says Moon of the Center for Aging, “It’s a sad commentary on what the candidates have to do to sell reform in the U.S.”

Veteran health care journalist Trudy Lieberman is Contributing Editor of the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care blog.

[Cropped photo by DonkeyHotey via Flickr.]