Last week in the Coons-O'Donnell debate in Delaware, we heard the Republican candidate, Christine O'Donnell, lay out her answer to health reform -- or "Obamacare" as she and the Republicans so sarcastically call it. She cranked out two of the three talking points that Republicans have been spouting for over two decades: 1) Malpractice reform 2) Selling insurance across state lines and 3) Personal responsibility for care (translated means more of the "consumer driven" plans that have high deductibles up front.)

It's time to call them out. Since the Clinton health reform effort failed in the early 1990s, Republicans have been making these same points. They had eight years during the Bush Administration to show that these three talking points or "solutions" could make a difference. They did nothing about it. Why? Because these three talking points would make little to no impact on the real problems health reform is trying to solve. Here's why.

1) Take malpractice reform. Please. For years, studies have shown that malpractice reform, while desirable for a variety of reasons, would have almost no impact on the reduction of health care costs.

In fact a new study , published last week in Health Affairs suggests that costs associated with medical malpractice are far less than the $650 billion figure (26% of all money spent on health care) cited by some Republicans who have made tort reform a cornerstone of their vision for "bending the cost curve" in health care. The newly calculated figure, $55.6 billion, represents just 2.4% of health costs.

Reform the malpractice and medical liability system? Of course. But don't make it the centerpiece of a plan to reform health care. At best it's a byline.

2) Selling insurance across state lines? Republicans love this idea. Why? Because the very sleaziest of health insurance products and companies -- the ones that have such high deductibles you might as well not even have insurance ($5000, $10,000), what they call "catastrophic" plans, are just waiting for your state to allow them in, to sell you stuff that has almost no value. There has been legislation over the years to allow this sale of policies across state lines, but the conclusion is that it would little to no impact on the real problems we face.

As Ezra Klein pointed out in the Washington Post awhile back, this is a terrible idea.

As it happens, the Congressional Budget Office looked at a bill along these lines back in 2005. They found that the legislation wouldn't change the number of the uninsured and would save the federal government about $12 billion between 2007 and 2015. That is to say, it would do very little in the aggregate.

But those top-line numbers hid a more depressing story. The legislation "would reduce the price of individual health insurance coverage for people expected to have relatively low health care costs, while increasing the price of coverage for those expected to have relatively high health care costs," CBO said. "Therefore, CBO expects that there would be an increase in the number of relatively healthy individuals, and a decrease in the number of individuals expected to have relatively high cost, who buy individual coverage."

That is to say, the legislation would not change the number of insured Americans or save much money, but it would make insurance more expensive for the sick and cheaper for the healthy, and lead to more healthy people with insurance and fewer sick people with insurance. It's a great proposal if you don't ever plan to be sick, and if you don't mind finding out that your insurer doesn't cover your illness. And it's the Republican plan for health-care reform.

3) Taking personal responsibility for your health? Wolf Blitzer asked O'Donnell last night if she approved of a person refusing to buy health insurance and then having the rest of us pay when that person gets sick and goes to the hospital. This is her non-response.

BLITZER: All right. Well, here's the question. Let's say someone decides not to purchase health insurance, makes that conscientious decision, even though this person can afford to buy health insurance, but decided he doesn't want to. This person gets critically ill, is rushed to an emergency room.

Should we, people who pay for health insurance, provide him or her with that kind of treatment, or should we kick them out of the emergency room, said, you made a decision, you're not going to get this kind of treatment?

O'DONNELL: If we do the things that I've said that will help to address
-- that I'm proposing, that will help to address the issue of health care, then that person can afford to buy a catastrophic-only policy from across state lines. They'll be able...

BLITZER: Well, what if the person doesn't want to buy it?

O'DONNELL: Well, then we have to address that.

BLITZER: Who should take care of that person in an emergency?

O'DONNELL: We have to address it.

BLITZER: Would we, all of us tax-payers...

O'DONNELL: We have to -- no, we have to...

BLITZER: ... have to pay for that person?

O'DONNELL: Anything that they do when they have another bill that they can't pay, make them pay it. Hold them accountable for that.

KARIBJANIAN: Before or after they get care?

O'DONNELL: But right now, right now -- well, that's up to the hospital.
But right now we're forcing them to. We're forcing them that they have to give care to illegal aliens...

O'DONNELL: Well, nobody should be forced to pay for anyone else's health care, and that's what Obamacare is doing.

COONS: And that's what's happening today. Before the health care reform bill passed, all of us who have health insurance, who have health coverage have been bearing the costs, paying the freight for those who don't have insurance and don't have coverage. They're getting health care through emergency rooms now. That's partly why small businesses, employers like New Castle County have faced double digit increases in our insurance costs year after year and year because that's how we provide care now, it's inefficient, it's inhumane and it's not effective.

Note that Chris Coons nailed that answer and O'Donnell unwittingly agreed with him.

This is the Republican answer to "personal accountability." If O'Donnell knew more, she would know that hospitals have to write off the care of that type of person, and when they do, they shift those costs wherever they can -- mainly to those of us who are paying customers. Personal accountability is fine if you have an extra $100,000 around to pay for your health care if you are uninsured and get sick. But if you don't, you lean on the rest of us.

O'Donnell missed the third and main Republican talking point on personal responsibility -- and that is the sale of consumer-driven or consumer-directed health plans, where the high up front deductible is meant to discourage people from seeking unnecessary care. Not a bad idea if it's a choice for people. If they have enough money to pay those deductibles before they get the care, fine. But it has been shown that consumer-driven products tend to work better with higher income consumers, and consumers tend to delay care when they enroll in those plans. The American Academy of Family Physicians offers this analysis:

A December 2005 survey by the Employee Benefit Research Institute (PDF file: 12 pages / 163 KB. More about PDFs.) notes that patients with consumer-directed or high-deductible health plans "were significantly more likely to avoid, skip or delay health care because of costs than were those with comprehensive insurance, with this behavior particularly pronounced among those with health problems or incomes under $50,000."

So that's the Republican Plan for reforming health care and lowering costs. As you listen to the debates in the next few weeks, raise a glass every time you hear those talking points (but be careful to drink something non-alcoholic or you'll pass out). And remember -- as complicated as health reform is -- and it is too complicated for three talking points -- it is the Democrats who attempted to really solve these problems and will continue to work on this year after year until all the wrinkles are ironed out. (By the way, might I note that reform has NOT yet been implemented fully and won't until 2014, so could the candidates please stop blaming reform for everything that is happening now?)

Slogans are easy to spout. Real reform is a lot harder.

UPDATE: In the debate between Harry Reid and Sharron Angle in Nevada, Ms. Angle mentioned two of the three Republican talking points as her solution -- malpractice reform and selling insurance across state lines. Have a drink everyone!!