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Health care has been invisible for most of the presidential campaign. That changed at last week’s presidential debate, when Donald Trump answered a question about his intentions on the Affordable Care Act (aka Obamacare).
First Trump claimed to have “saved” the 2010 health care law despite having spent the first year of his presidency trying to repeal it. Then he promised that he had “concepts of a plan” for replacing it.
Trump didn’t specify what these concepts were, which was nothing new. The Republican presidential nominee has been promising a mythical, never-defined plan that will provide “great health care for much less money” since he first started talking about repealing Obamacare in his 2016 presidential campaign.
But over the weekend, his running mate, Sen. JD Vance of Ohio, said Trump actually did have an alternative. During an appearance on NBC’s “Meet the Press,” Vance said Trump had in mind a “deregulatory agenda so that people can choose a health care plan that fits them.”
Americans have different health care needs, Vance explained, so it makes sense to “promote some more choice in our health care system and not have a one-size-fits-all approach that puts a lot of people into the same insurance pools, into the same risk pools, that actually makes it harder for people to make the right choices for their families.”
Those of us who follow health care policy closely understood immediately what he meant.
At any one time, most people aren’t spending a lot on medical care because most people are in relatively good health. The vast majority of costs come from the minority who are getting intensive or ongoing treatment for serious medical problems ― basically anything from a car accident to diabetes to cancer.
The challenge in health policy is how to cover those big expenses. The approach in most economically advanced countries ― and the one embedded here in programs like the Affordable Care Act ― is to have everybody contribute into insurance funds so that the healthy subsidize the sick. These are the “insurance pools” and “risk pools” that Vance is criticizing.
The alternative is to allow more segregation based on health status by, for example, letting insurers charge higher prices, withhold certain benefits or deny coverage altogether to people with pre-existing conditions.
This can work out well for people in good health, at least in the short term, because they will be comfortable buying barebones plans that insurers will charge less for. But they’re likely to face trouble if they need serious medical care ― as most people do eventually ― because their insurance won’t cover their needs.
And that’s to say nothing of the people who’d already had major health problems and couldn’t even find insurance in the first place.
This is the way things worked for many Americans before Obamacare, and it’s the way things would work once again under Affordable Care Act replacements that conservatives have touted in the past.
Vance was careful to say he and Trump would “make sure everybody is covered,” just as Trump has promised before. But the actual plans Republicans put forward during the 2017 repeal fight would have caused the number of Americans without insurance to rise by millions or even tens of millions, partly because they did not protect people with pre-existing conditions, partly because they simultaneously proposed to slash funding for Medicaid, the program the insures low-income Americans.
And that’s not surprising. Conservatives don’t merely want to reduce the cross-subsidy between healthy and sick. They also want to free up money for tax cuts that would disproportionately benefit the wealthy, something, it so happens, that Trump and the Republicans still want to do.
Of course, cutting health care programs to finance tax cuts isn’t especially popular. Neither is undermining protections for people with pre-existing conditions. Republicans know this too well. The 2017 repeal effort was a political catastrophe for them and it’s why nowadays they don’t go out of their way to talk up the cause.
But that doesn’t mean they’ve given up or that they couldn’t scrounge up the votes if they were back in control of Washington. Just consider some comments a Republican House candidate in a key swing district made over the summer.
A Pair Of Comments ― And What They Could Mean
The candidate, Alison Esposito, is running in New York’s 18th Congressional District. Like most Republicans on the ballot this year, she hasn’t had a lot to say about health care. But questions about it came up at campaign events twice over the summer, according to recordings a source provided to HuffPost.
The first came at a local conservative meeting in July. An audience member mentioned that Trump last fall had posted on social media that Republicans should “never give up” trying to “terminate” the Affordable Care Act and that, if elected to a new term, he would replace it with a still-unspecified “better” alternative.
“I’m wondering if that’s something that you support or something that you could speak to,” the audience member said.
Esposito responded, “Well, yes, there has to be a better system of health care in place.” Later she said that “Obamacare doesn’t work.”
The Affordable Care Act isn’t the only Democratic health care initiative that has attracted the ire of Republicans. Another is the Inflation Reduction Act, the sweeping 2022 climate and health care law. Among its provisions is a series of initiatives to bring down drug prices in Medicare by, for example, capping insulin costs at $35 a month and allowing the federal government to bargain down the prices of certain high-cost medications.
That program’s future was the subject of the second question Esposito got, this time during an electronic town hall in August. “Would you vote to repeal the Inflation Reduction Act?” a questioner asked Esposito.
“Yeah,” she responded. “That act was reckless, and [Vice President] Kamala Harris was the deciding vote for the printing of money and irresponsibly and recklessly putting it into our system, our budgets.”
The questions, to be clear, weren’t that specific. And Esposito’s answers were certainly open to interpretation. Did she actually mean to endorse repeal of the Affordable Care Act? Does she really want to roll back the Inflation Reduction Act’s prescription drug reforms?
But when HuffPost put those questions directly to her campaign, the response, given by a spokesperson, was to bemoan the high cost of health care, attack Biden for supposedly undermining part of Medicare and promise that Esposito would “find ways for everyone to find the healthcare coverage that works best for them and their family.”
Conspicuously lacking from the statement was any denial that Esposito wants to repeal the drug pricing reforms or Obamacare. The district’s Democratic incumbent, Pat Ryan, has a history of supporting both programs. And though Esposito may not be looking to lead a crusade against either program, other Republicans might be.
Project 2025, the Heritage Foundation’s governing agenda for a second Trump term, calls for rolling back both the drug pricing reforms and key pieces of the Affordable Care Act. So does the latest budget from the Republican Study Committee, which represents conservatives in the U.S. House.
And just this week, an article in Axios quoted two high-profile Republican lawmakers saying they were looking to repeal the new drug pricing reforms ― an effort that, it probably goes without saying, would get a strong outside boost from the pharmaceutical industry.
The logic here is no mystery. Conservatives believe the drug price reductions will ultimately discourage innovation, just as they believe the Affordable Care Act’s rules make the insurance markets less efficient. It’s all part of their broader conviction that the federal government ends up doing more harm than good when it gets involved in health care.
And Trump? He hasn’t said specifically what he thinks about the drug pricing changes. When Axios asked the campaign for his position, the response was a boilerplate statement from a spokesperson that Trump “will release more details but his overall position on health care remains the same: bring down costs and increase the quality of care by improving competition in the marketplace.”
It’s the exact same response HuffPost got last week when it asked the Trump campaign to clarify his position on Medicaid and an awful lot like what Esposito said when asked to clarify her comments over the summer. Given opportunities to stand up for these programs, they declined. That says a lot.