In Open GOP Race, a Narrow Divide on Health Policy

The top White House contenders all want to repeal and replace Obamacare, but haven’t offered much detail on how.

From left, Sen. Marco Rubio, Donald Trump, and Sen. Ted Cruz speak and gesture during a Republican presidential primary debate at The University of Houston on Feb. 25.
AP Photo/David J. Phillip
Rachel Roubein
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Rachel Roubein
March 3, 2016, 8 p.m.

On last Thursday’s de­bate stage, Don­ald Trump spoke vaguely about al­low­ing in­surers to sell across state lines and was met with jabs on his lack of a com­pre­hens­ive ap­proach to re­pla­cing Obama­care.

“What is your plan? What is your plan on health care?” Sen. Marco Ru­bio asked. “You don’t have a plan. I’ll give him one minute of my time to pro­pose a plan.”

A week later, Trump has a sev­en-point plan to show­case, one that was ad­ded to his web­site just 24 hours be­fore Thursday’s Re­pub­lic­an face-off. But some say the pro­pos­al isn’t a de­tailed al­tern­at­ive to the Af­ford­able Care Act—and that none of the GOP can­did­ates have in-depth, com­pre­hens­ive health care plans. That’s by design, it isn’t sur­pris­ing, and it isn’t new, sev­er­al health ex­perts said.

A de­tailed plan in­vites cri­ti­cisms of the pro­pos­al. It leads to ques­tions on fin­an­cing. And it boxes a can­did­ate-turned-pres­id­ent in­to policy pledges they made dur­ing their cam­paign.

Per­haps most not­ably, for Re­pub­lic­ans, health care isn’t the top vot­ing is­sue. It’s out­ranked by the eco­nomy and jobs, for­eign policy, pres­id­en­tial can­did­ates’ char­ac­ter­ist­ics or po­s­i­tions on the is­sues, and im­mig­ra­tion, ac­cord­ing to a Feb­ru­ary Kais­er Fam­ily Found­a­tion poll.

“Re­peal­ing the ACA is red meat for Re­pub­lic­an primary voters,” Larry Levitt, a Kais­er seni­or vice pres­id­ent, said, “but get­ting any more de­tail than that simply puts a tar­get on your back.”

The con­tenders say they want to re­peal and re­place the Af­ford­able Care Act and have men­tioned pro­pos­als that gen­er­ally take a page from GOP health or­tho­doxy. But Trump’s plan in­cludes im­port­ing pre­scrip­tion drugs from abroad—a staple of both Hil­lary Clin­ton’s and Bernie Sanders’s health plans. Trump has also stated that he would sup­port al­low­ing Medi­care to ne­go­ti­ate drug prices—an­oth­er com­pon­ent of the two Demo­crats’ plans—but his latest health pro­pos­al makes no men­tion of this no­tion.

In Au­gust, Ru­bio penned an op-ed in Politico titled “My Plan to Fix Health Care,” where he wrote about his com­mit­ment to re­peal­ing Obama­care and re­pla­cing it with “mod­ern, con­sumer-centered re­forms that lower costs, em­brace in­nov­a­tion in health­care, and ac­tu­ally in­crease choices and im­prove qual­ity of care.” Ru­bio dis­cussed three primary com­pon­ents of a re­place­ment plan, ideas which are also fea­tured on his web­site. His pro­pos­als in­clude giv­ing Amer­ic­ans an ad­vance­able, re­fund­able tax cred­it to buy in­sur­ance; help­ing those with preex­ist­ing con­di­tions get af­ford­able cov­er­age; and giv­ing states a per-cap­ita block grant for Medi­caid.

Last month, Trump tweeted his ver­sion of what health care would look like in a Trump ad­min­is­tra­tion: “I will re­place it with private plans, health sav­ings ac­counts, & al­low pur­chas­ing across state lines. Max­im­um choice & free­dom for con­sumer.” After cri­ti­cism from last week’s de­bate, he re­leased his sev­en-point plan Wed­nes­day, which ex­pounds upon his ideas.

In Janu­ary, Sen. Ted Cruz came un­der fire in Iowa when a voter pressed the can­did­ate on how he would re­place Obama­care. Cruz hasn’t touted the re­lease of a plan on­line—though he has dis­cussed what he would do at de­bates. At one in Feb­ru­ary, Cruz men­tioned three re­forms he’d make after re­peal: Al­low con­sumers to buy in­sur­ance plans across state lines, ex­pand health sav­ings ac­counts, and break the ties between in­sur­ance and em­ploy­ment.

Gov. John Kasich has re­peatedly de­fen­ded his de­cision to ex­pand Medi­caid in Ohio. But he says he’s for re­peal­ing the ACA, and ac­cord­ing to his web­site, he’d like to see changes that fo­cus on “pa­tient-centered care, choices, mar­ket com­pet­i­tion, de­cent­ral­ized de­cision-mak­ing, high­er qual­ity, re­spect for in­di­vidu­als, and an end to Obama­care’s big gov­ern­ment in­ter­fer­ence.”

The lack of in­tric­ate plans isn’t a new phe­nomen­on, ac­cord­ing to Gail Wi­lensky, who dir­ec­ted the Medi­care and Medi­caid pro­grams from 1990 to 1992 and was a seni­or health and wel­fare ad­visor to Pres­id­ent George H.W. Bush.

The ra­tionale? “Re­pub­lic­ans tra­di­tion­ally have fo­cused less on health care than Demo­crats and thus the Re­pub­lic­an can­did­ates’ pro­pos­als on health care changes and re­forms are un­likely to be im­port­ant reas­ons for Re­pub­lic­an primary voters to use to choose among vari­ous can­did­ates,” Wi­lensky, now an eco­nom­ist and seni­or fel­low at Pro­ject HOPE, wrote in a Mil­bank Quarterly art­icle pub­lished Wed­nes­day.

In an email Thursday, Wi­lensky wrote that the re­lease of Trump’s “non-plan,” as she called it, doesn’t change mat­ters much: “[It] just looks a little more like a pro­gram be­cause there’s more word­ing and the lay­out—it’s the sub­stance that’s lack­ing to deal with most of the un­in­sured that makes it a ‘non-plan.’”

Yet, some ar­gue that can­did­ates shouldn’t be shy on spe­cif­ics, but rather bring good plans to the fore­front of a cam­paign. “I think it would put Obama­care front and cen­ter in the way that it should be and hasn’t been,” said Jef­frey An­der­son, a Hud­son In­sti­tute seni­or fel­low. “The Re­pub­lic­an can­did­ates ought to be telling the Amer­ic­an people—and for now, voters—what they would do. If you want to re­peal Obama­care, it’s pretty ob­vi­ous you have to have an al­tern­at­ive.”

And if a can­did­ate be­lieves his or her policy is sound, An­der­son said, why not get it out there?

Though the primary sea­son so far hasn’t seen the level of flu­ency in health care that An­der­son would like, that could change dur­ing gen­er­al-elec­tion sea­son, as a Demo­crat­ic con­tender pres­sures their Re­pub­lic­an chal­lenger to talk about their de­tailed plans, and both can­did­ates vie for in­de­pend­ent voters.

“The con­trast on health care in the gen­er­al elec­tion will be quite sig­ni­fic­ant,” Levitt said. “It’s al­ways hard to pre­dict which is­sues will be most prom­in­ent and most sa­li­ent, but I think health care will provide an ex­ample of how the elec­tion could lead to a very dif­fer­ent fu­ture.”

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