Analyzing the policy positions taken by President Donald Trump and former Vice President Joe Biden at Tuesday’s anarchic debate is like critiquing the footwear of the fighters in a steel cage match. The evening wasn’t about policy, it was about force — and more precisely, it was about Trump trying to batter Biden into incoherence with his relentless interruptions, attacks and wild claims.
Nevertheless, the two candidates made some points about health care early in the evening that are worth resurrecting from the wreckage because they illustrate how much of Trump’s presidency has been about symbolic moves instead of substantive ones.
The issue came up amid a discussion about Trump’s nomination of conservative jurist Amy Coney Barrett to replace the late liberal Supreme Court Justice Ruth Bader Ginsburg. Biden said that Trump is “in the Supreme Court right now trying to get rid of the Affordable Care Act, which will strip 20 million people from having health insurance.”
He’s right about that — at the White House’s insistence, the Justice Department has joined with several Republican state attorneys general in asking the court to throw out the entire ACA, eliminating the Medicaid expansion and subsidized state insurance exchanges that have enabled millions of lower-income Americans to obtain coverage. The lawsuit is an exercise in legal sophistry with potentially grave consequences.
Biden also observed that killing the ACA would allow insurers to resume discriminating against people who have pre-existing conditions and who are not covered by an employer’s group insurance policy. “Once again, a woman could pay more money because she has a pre-existing condition of pregnancy,” Biden said, adding that insurers would also “be able to charge women more for the same exact procedure a man gets.” He later noted that the roughly 7 million Americans who have survived COVID-19 may also find themselves hurt by the elimination of those protections.
Trump defended his efforts to eliminate the ACA and the coverage it provides to millions of Americans, saying, “I want to give them better health care at a much lower price, because Obamacare is no good.” In fact, he claimed, “We made it better and I had a choice to make very early on. We took away the individual mandate. We guaranteed pre-existing conditions, but took away the individual mandate. Listen, this is the way it is. And that destroyed ... they shouldn’t even call it Obamacare.”
So much to unpack there, but let’s start with the obvious. The executive order Trump issued last week that supposedly guarantees coverage for pre-existing conditions doesn’t actually do anything. It states that “It has been and will continue to be the policy of the United States to give Americans seeking health care more choice, lower costs, and better care and to ensure that Americans with pre-existing conditions can obtain the insurance of their choice at affordable rates.” But it does not actually stop insurers from discriminating against people whom they don’t want to cover, or influence the rates they charge.
Meanwhile, attacking the individual mandate is just one of many things Trump’s administration has done to discourage younger, healthier people from signing up for Obamacare, which is one reason premiums rose so dramatically in the first years of his term. Seemingly every health insurance move Trump has made, aside from his efforts on surprise medical bills and prescription drugs, has been designed to draw healthy people away from the sort of comprehensive insurance that people with pre-existing conditions need, reducing the pool of ratepayers and driving up premiums for those in the plans. It’s been a relentless, multi-front attack that leaves a huge number of people potentially vulnerable; the Kaiser Family Foundation estimates that more than a quarter of American adults below age 65 have the kind of pre-existing conditions that could render them uninsurable should they lose their group coverage and the ACA no longer exists.
Trump claimed, risibly, that he instructed his administration to run Obamacare well, but “they said the problem is, no matter how well you run Obamacare, it’s a disaster” because of high premiums. It’s true that the comprehensive coverage that Obamacare requires is costlier than thinner insurance policies, but as Trump’s critics and independent analysts have pointed out repeatedly, this administration’s actions have only made those costs go up.
Tellingly, Trump had no good answer when moderator Chris Wallace of Fox News pressed him to outline the plan for offering better, more affordable health care that the president has been promising since he became a candidate in 2015. That’s because Trump has no such plan. Instead, he has taken a series of executive actions that may help on some fronts, such as his push to lower the cost of some prescription drugs, and that have demonstrably hurt on others.
Biden does have a plan, which includes expanding federal premium subsidies for people not covered by group policies at work and offering a government-run insurance option to compete with private insurers. Trump ignored Biden’s proposal and appeared to focus instead on the “Medicare for All” plan that Sen. Bernie Sanders, I-Vt., has championed, which would eliminate private insurance coverage.
Wallace tried to get Biden to discuss whether the public option would eventually force out private insurers, as some critics contend. But he had barely gotten started explaining how it would work — focusing on how the public option would help low-income Americans in states that have not expanded their Medicaid programs — before Trump jumped in to contradict him. “Joe, you agreed with Bernie Sanders, who’s far left, on the manifesto, we call it. And that gives you socialized medicine,” Trump said, grossly distorting what Biden and Sanders jointly endorsed.
Biden eventually responded, almost in resignation, “The fact is that everything he’s saying so far is simply a lie.” Which wasn’t entirely correct; Trump mixed in the occasional nugget of truth about his actions on health care. But to find them you had to dig through a lot of false and misleading assertions, the most egregious of which were Trump’s claims that he is trying to protect people with pre-existing conditions.
Jon Healey is the Los Angeles Times’ deputy editorial page editor.