The Health Care Debate That Wasn't

DETROIT Health care dominated the first part of Wednesday’s Democratic presidential debate, just like on Tuesday, only this time, the conversation was more cacophonous, disjointed and hostile. 

Multiple candidates accused each other of lying, made misleading statements, or ignored criticism of their plans and records. Neither of the two front-runners onstage, former Vice President Joe Biden and Sen. Kamala Harris (D-Calif.), made particularly coherent arguments for their proposals.

The contrast with Tuesday night’s  confident, clear presentations by Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.) was conspicuous. And while that might be good news for Sanders and Warren, it’s probably not good for Democrats overall or for the tens of millions of Americans still struggling with the cost of health care. 

Democratic voters have some important decisions to make about which plan and which candidate can do the most to make health care more affordable. Every proposal now on the table has its pluses and minuses, and the voters need to understand those trade-offs.

But Wednesday’s spectacle, especially the testy exchanges between Biden and Harris, quite possibly left them more confused than before. 

It didn’t have to be that way. The political landscape on health care is pretty easy to describe and it actually features more consensus than Wednesday’s melees conveyed. All the Democrats running for president want to get to universal coverage  by defending the Affordable Care Act from Republican assaults and then figuring out how to fill in its many gaps. 

All would spend more government money subsidizing insurance to reduce premiums and out-of-pocket costs. All would expand existing public programs or create new ones, on the theory that such programs are more efficient and humane than private alternatives. All would have the government use its power to lower prices, on the theory that regulation can accomplish what competition has not.

Where the Democrats differ is over how far to go in these directions and how quickly. 

Biden wants to build upon the Affordable Care Act by making its financial assistance more generous, creating a public plan that would be available to anybody, and by getting government more involved in the pricing of prescription drugs. Millions would get relief, and they probably could get it quickly, since a Democratic Congress could swiftly pass at least part of the proposal.

Sanders and Warren want to create a single, government-run, “Medicare for All ” plan that would enroll every American, displacing all existing arrangements and dictating prices to every provider and supplier of health care in the country. Everybody would have insurance, nobody would owe out-of-pocket costs, and health care spending would probably come down over time.

The other leading candidates are in the middle, and that includes Harris. On Monday, she proposed creating a new government insurance program that would become the default option for everybody while still allowing private insurers to offer an alternative. Harris also envisions a 10-year transition to the new system, rather than the four-year transition Sanders has in his proposal.

An honest politician could make a respectable argument for any of these positions. And on Wednesday, the two front-runners onstage did a bit of this, like when Biden noted (correctly) that his plan would be a lot less expensive for taxpayers or when Harris stated (correctly) that a voluntary version of Medicare for All, rather than one with mandatory enrollment, is what voters seem to crave right now .

But then the back-and-forth started, and accuracy went out the window. In response to a Harris attack, Biden said his plan “will cover everyone.” It wouldn’t. In response to Biden accusations that her plan’s expense would blow up in the second decade and end existing employer plans, Harris said those charges were “inaccurate.” But they were accurate .

Other candidates made misleading statements, too. Sen. Michael Bennet (D-Colo.), who also supports more incremental changes, said offering a limited version of the public option would lead to “universal health care in this country in two years, not 10 years.” But the kind of plan Bennet has endorsed wouldn’t get us universal coverage in two years or, really, ever.

More often than not, though, the candidates weren’t making misstatements so much as they were simply talking past each other, ignoring questions or criticism to make their own points. And even then, their statements were so opaque and jargon-laden that they were nearly impossible to follow.

In one particularly inscrutable sequence, Biden started talking about Republican attacks on Obamacare, then shifted his focus to the insurance deductibles his proposal would allow, and then said the real deductibles to worry about were the high costs of Medicare for All. Harris responded by talking about insurance company profits, the drug industry’s role in the opioid crisis and the high cost of insulin. And all of that was in the span of about 45 seconds.

The debate format was partly to blame, with so many candidates representing so many different views trying so desperately to get attention in limited time. But the candidates also bear some responsibility, and that was especially true of Biden and Harris, who simply seemed less familiar with health policy and less capable of pressing their arguments than either Sanders and Warren had been on Tuesday.

The approaches to health care that Biden or Harris advocate may be closer to what Democratic voters want. Or they might not be. The only way to find out is to make sure voters understand how the different approaches work — and, at least on Wednesday, Biden and Harris weren’t much help.