Tuesday night, U.S. Senators Bernie Sanders (D-VT) and Ted Cruz (R-TX) debated on national TV about healthcare and the Affordable Care Act. Both senators made statements we have come to expect from them. Sanders generally supported the ACA, but argues that it doesn’t go far enough and should be replaced with Medicare for all. Cruz hammered Obamacare and recycled squishy claims about people losing their insurance and that government intervention is the main problem with healthcare. Both candidates took shots at each other, suggesting the Republicans are going to kick millions off of their health insurance and that Democrats support government intruding in decisions between people and their doctors. In some cases, there was actually agreement between the two senators, especially in their support for allowing the importation of prescription drugs.
What was probably the most interesting was what each senator avoiding saying. Several times Cruz criticized the rationing of care in countries with single-payer systems. Bernie Sanders did not put up a strong argument against that potential issue and instead shifted focus away by arguing that rationing occurs in the United States, but it is the insurance companies and not the government. In a couple cases, he simply conceded that these problems may exist in single-payer systems.
On the other hand, Cruz refused to answer whether or not he felt that healthcare was a right or a privilege. When Sanders asked Cruz the question directly, Cruz diverted to a constitutional definition of a “right” and pivoted to his general argument that government should stay out of healthcare. Perhaps Sanders should have used the word “entitlement” instead of “right,” but Cruz likely knew exactly what Sanders was asking. He said nothing to suggest that he supports universal coverage and was clearly trying to avoid saying that he thinks healthcare is a privilege.
In a political battle when the goal is passing landmark legislation, the warrior who dives in with the intent of ideologically browbeating their opponent into submission probably will not prevail. Unless you have a sufficient majority (60 Senate votes in the case of the American system), compromise and common ground must be found in order to achieve results. The problem is that when it comes to compromise, people are extremely unlikely if not incapable of compromising deeply held values. In the case of healthcare, there seem to be diametrically opposed values on the two sides of the debate.
The Sanders-Cruz debate demonstrated the values that each side holds when it comes to healthcare. Democrats are very clear in their position that healthcare is right and Americans should be entitled to receive the healthcare that they need. Republicans by and large do not support universal healthcare and their overall values around less government and lower taxes work against the effort to provide healthcare to all. There also appears to be resistance on the Republican side to standardization that could potentially compromise quality to those who are able and willing to pay for it. The Affordable Care Act did not reach universal healthcare, but it significantly reduced the number uninsured Americans. It is no surprise that Sanders is looking to take the next step toward single-payer and Cruz is taken aback by the cost of insuring so many.
These values came through as the candidates answered questions. One woman asked Sanders what he would do to help her to expand her hair salon business. She stated that she deliberately keeps her business below the 50 employee threshold to avoid a mandate to provide her employees healthcare. I doubt that his answer was satisfactory to her, because he simply said that he believes she should be compelled to provide her employees health insurance. I thought Bernie missed an opportunity here, because he could have made a very compelling case for health insurance to be decoupled from employment, a strong argument for his Medicare for everyone proposal.
A woman who with multiple sclerosis asked Ted Cruz what he will do to ensure that she doesn’t lose the Medicaid coverage under the ACA that saved her life. Cruz’s answer focused on trying to reduce the cost of private health insurance policies. While everybody would love to see prices come down, that doesn’t help someone who can’t afford to pay anything. Cruz made it abundantly clear that the GOP has no replacement plan that would cover people who cannot afford insurance, nor do they have any intention of covering everyone, including the woman who asked the question.
A January 2017 poll by Pew Research shows that 60% believe that it is the government’s responsibility to ensure that all Americans have healthcare coverage. While there is a strong partisan divide with Democratic support at 85% and Republican support at 32%, the most interesting data is when you combine party ID and income levels. Democrats, regardless of income, report about 85% support demonstrating the idea of universal healthcare as a deeply held value. Republicans tend to prioritize other issues and the support for government ensuring healthcare coverage tracks more closely with the likelihood of someone needing help to afford healthcare. Among Republicans, 18% of with incomes above $75,000, 34% with incomes between $30,000 and $75,000, and 52% with incomes under $30,000 support the government ensuring coverage. Republican opinion is driven largely by individual need while Democratic opinion is driven by an intrinsic value.
Over the last few weeks we have seen the Republican’s effort to swiftly repeal every word of Obamacare stalling. We have gone through phases of repeal and delay, repeal and replace, and now we are seeing some key members of Congress suggesting that they will not repeal at all and instead just try to fix it. Some have even suggested that they won’t be able to do anything without bipartisan support. While it is not difficult to point out the problems and unintended consequences associated with the Affordable Care Act, now that people are facing the reality that it may go away, we are finding that American’s value a society where healthcare is a right and not a privilege. Republicans will not come to a partisan consensus on repeal or replace because many realize that it is political suicide. If they want to do something, they will never find consensus because of the members who will accept nothing short of repeal. The most likely outcome is that nothing happens, because they will need Democrats that have no motivation to weaken a system where millions now have access to health insurance that did not have it before.