Clinton Offered A Nuanced Answer On Obamacare; Trump Offered Policy Word Salad

Obamacare got some serious attention in Sunday’s town hall debate , following an audience question about why insurance seemed to be getting more and more expensive, while covering less and less.

The answers from Hillary Clinton and Donald Trump provided a near-perfect distillation of very different ways they think about the world and how, most likely, they would govern as president.

Clinton gave a nuanced response. The Democratic nominee sketched out what she believes are the Affordable Care Act’s strengths and weaknesses, vowing to address the latter with a series of modest changes that she’d outlined previously in her speeches and writings.

Trump decried Obamacare as a “disaster,” giving a hyperbolic account of its flaws with zero acknowledgement of its virtues. Then the Republican nominee promised he’d give Americans the “finest health care plan there is,” even though he’s never sketched out a detailed alternative.

What’s Actually Happening With Obamacare

To process what the candidates were saying, it helps to get an accurate picture of what’s actually happening with Obamacare these days. 

The law has allowed something like 20 million people to get insurance, bringing the number of uninsured to a record low. Predictions that the law would cause national health care costs to skyrocket have proved spectacularly wrong, as have predictions that the law would cause the deficit to explode or kill the job market.

Obamacare has also ended insurance company practices that caused misery for the minority of Americans buying coverage on their own, rather than through employers practices like denying coverage to people with pre-existing conditions, or selling skimpy plans that left out benefits like mental health and rehabilitative services.

The trouble is that those changes also made coverage more expensive, since insurers are now covering people and services they used to avoid. And although millions benefit from tax credits that offset these higher prices, millions do not. They face prices much higher than they expected or feel they should pay and one side effect is that many of these people are electing to go without coverage, upsetting the delicate actuarial balance insurers need to cover their costs.

That’s why insurers are jacking up prices this year and why big commercial insurers are pulling out of some markets altogether. In some parts of the country, consumers have only one insurance option. Meanwhile, even many of the insured still face high out-of-pocket costs and are finding the only affordable plans have narrow networks of providers.

What Clinton Said About Obamacare

During the debate, Clinton made the same argument she’s made so many times before that the pluses of Obamacare far outweigh the minuses, so the best next step is to fix the law’s shortcomings. And although she ran out of time to describe these steps in detail, she has said previously she would focus on reducing the cost of prescription drugs and providing more financial assistance to people with particularly onerous premiums and out-of-pocket costs.

Whether she’s weighed the ups and downs of the law appropriately, whether her sometimes vague proposals would improve access to health care at a reasonable price these are subjective questions, about which reasonable people can disagree. But the facts she cited on Sunday night were correct, and she’s outlined her policy plans clearly, if not always with much detail.

What Trump Said About Obamacare

Trump had actually started talking about Obamacare in his opening statement when he said that premiums were going up “with numbers that are astronomical, 68 percent, 71 percent.” Then, after Clinton had given her assessment of the law, he continued with the theme:

Obamacare is a disaster. You know it. We all know it. It’s going up at numbers that nobody’s seen worldwide. Nobody’s ever seen numbers like this for health care. Only gets worse. Their method of fixing it is to go back and ask Congress for more and more money. We have almost $20 trillion in debt. Obamacare will never work. It’s very bad. Very bad health insurance. Far too expensive. And not only expensive for the person that has it, unbelievably expensive for our country. One of the biggest line items very shortly.

Premiums are rising more quickly this year, with insurers requesting an average increase of 25 percent, according to Charles Gaba of acasignups.net. That’s an average, with a great deal of variation and there are, in fact, people whose plans are getting dramatically more expensive next year.

But as HuffPost’s Jeffrey Young pointed out on Sunday  most people facing increases will be able to switch to cheaper plans, and of course millions will get tax credits that amount to huge discounts. That’s little consolation to the millions who don’t get big tax credits, but, as a recent analysis from the Urban Institute pointed out, on average the plans the law makes available are not more expensive than the ones employers provide employees. If anything, they are a little cheaper.

Later Trump suggested that Clinton’s solution, providing more financial assistance to people with higher expenses, was a bad idea because the country already has “almost $20 trillion in debt.” But Clinton has called for raising taxes on wealthy Americans in order to pay for her new initiatives, including the proposed health care assistance, and the Committee for a Responsible Federal Budget an independent organization that is obsessive about reducing the deficit has concluded she’s identified enough specific revenue to pay for nearly her entire agenda.

When the Committee analyzed Trump’s plans, by contrast, it determined that they would add $5.3 trillion in new debt over the next 10 years.

At one point, Trump suggested that Clinton actually preferred to create a single-payer plan something that would come as a great shock to Sen. Bernie Sanders  (I-Vt.), who proposed a single-payer scheme during the Democratic primaries that Clinton attacked repeatedly. (Trump also suggested that single-payer plans are “catastrophic” in certain ways, even though those systems actually outperform the U.S. system by at least some metrics, while managing to provide truly universal coverage with significantly lower spending.)

But the most telling part of Trump’s answer was when he described his alternative. After making the case for allowing cross-state purchase of insurance which would potentially lower premiums, but only by allowing insurers to escape existing regulations on benefits and sales practices Trump said the following:

When we get rid of those lines, you have competition and we’ll be able to keep pre-existing and help people that can’t get, don’t have money because we are going to have people protected. And Republicans feel this way. Believe it or not and strongly this way. We’re going to block grant. Into the states. Block grant into medicaid. So we will be able to take care of people without the necessary funds to take care of themselves.

This is word salad worthy of Sarah Palin. Even the comprehensible parts don’t make sense. Allowing insurance sales across state lines, for example, won’t enable people with pre-existing conditions to get insurance. If anything, it will have the opposite effect, since some states have historically forced insurers to sell to all comers and allowing cross-state purchasing would render those regulations moot. Republican schemes to block grant Medicaid typically involve reducing the program’s funding, which would, according to impartial estimates, vastly reduce the number of people who could get insurance.

On Twitter, physician-author Atul Gawande said what most analysts listening to Trump were probably thinking: “I am still trying to decipher what Trump proposed as a health policy and I have no idea what he was talking about.”

Of course, Trump probably had no idea, either.