On Health Care, the 2020 Presidential Race Pits Bad Ideas Against Bad Faith

Supreme Court Justice Ruth Bader Ginsburg’s death elevates a familiar health care policy dynamic to the foreground of the election.

Supreme Court Justice Ruth Bader Ginsburg's death last week has thrown the presidential race into chaos. By once again placing health care policy in the foreground of the election, it has unleashed a more familiar political dynamic, in which bad ideas are pitted against bad faith. 

Following Ginsburg's passing, Democratic presidential nominee Joe Biden signaled that he would respond by elevating health policy issues in the race. The Supreme Court is currently scheduled to hear a challenge to Obamacare shortly after the election; a Trump appointee to the court, the argument goes, might be more sympathetic to the challengers than a Biden nominee. The Trump administration, meanwhile, has taken the unusual step of declining to defend the law, arguing that it should be struck down in federal court. 

There's a clear political logic to Biden's move: Polling suggests that the single most effective issue for Democrats in the 2018 midterm election, where they overtook Republicans in the House, was health care. Democrats argued that Republicans who opposed Obamacare would eliminate the law's regulations governing how insurance companies must treat individuals with preexisting conditions; many polls show those regulations are popular (although public support falls when the public is told about their costs). Republicans appear to have suffered at the polls accordingly, with Republican leaders admitting privately that the issue cost them seats. Biden's plan appears to be to rerun the messaging strategy that proved most successful for Democrats in 2018. 

In doing so, however, Biden will inevitably highlight his own health care plan, which he has billed as an attempt to build on Obamacare. But Biden's plan is better understood as an admission that the law, which Biden helped promote and pass as vice president, has not worked as promised. Biden would spend $750 billion, according to his own campaign estimates, to set up a government-run insurance plan, expanding both the law's coverage subsidies and eligibility for them, in order to accomplish the goals the original law was supposed to accomplish on its own. 

As conservative health policy analyst Chris Jacobs notes in The Wall Street Journal, a little-noticed provision in Biden's plan could end up providing incentives for individuals to move away from employer-sponsored coverage, substantially driving up federal spending on subsidies in the process. Jacobs estimates this effect could raise the cost of Biden's plan to $2.2 trillion, in part by expanding subsidies for people who are already (or would otherwise be) covered by employer-sponsored insurance. Meanwhile, employers would be left providing coverage for older, sicker workers whose premiums would presumably rise; employers might also face higher taxes stemming from Obamacare's employer coverage mandate.  

Employer-sponsored health coverage, an artifact of tax code preferences for workplace benefits, has many downsides, and should not be preserved at all cost. But Biden's plan could upend it in a way that is both expensive to taxpayers and disruptive to current private insurance arrangements with little commensurate benefit. Like so many Democratic plans before it, it's a kludgey technocratic misfire almost certain to result in unintended consequences

Biden's plan to emphasize health care in the wake of Ginsburg's death, however, will likely put pressure on Trump to explicate the details of his own health policy preferences. This may prove difficult because Trump himself has never provided any sign that his health care plan is anything other than disingenuous gobbledygook. 

That was on display last week during a town hall forum with George Stephanopolous of ABC News, during which an attendee asked Trump about his plan for health care and how he would protect individuals with existing health maladies. 

What followed was a contentious exchange in which Trump first promised that a new health care plan was coming that would protect preexisting conditions. Stephanopolous responded by noting that Trump has for over a year promised a new health care plan was coming in the space of just a few weeks, but no such plan has ever materialized; the host also noted that the Trump administration is currently backing a lawsuit to end Obamacare, including its regulations governing the sale and pricing of health coverage to people with preexisting conditions. 

Trump shot back with a garbled word salad that included the following elements: criticism of Obamacare, a claim that he effectively repealed Obamacare by repealing its individual mandate (which is not true), a claim that he ran Obamacare better than Obama (which has some merit), and criticism of Medicare for All (which his rival Joe Biden does not support). Perhaps most surprising was his insistence that, in fact, his health care plan already existed. "I have it already, and it's a much better plan for you, and it's a much better plan," he said, adding shortly after: "You're going to have new health care. And the preexisting condition aspect of it will always be in my plan." 

The notion that Trump's new health care plan exists already was surprising because the administration has released no such plan. Indeed, its existence was news to three Trump administration health officials last week, all of whom denied knowing about any such plan.

Perhaps others in the administration were working on it? That was what White House Press Secretary Kayleigh McEnany suggested when pressed on the issue during a briefing. But McEnany wouldn't provide any details about what was in the plan or who was producing it. Asked for specifics by a CNN reporter, McEnany responded curtly: "I'm not going to give you a readout of what our healthcare plan looks like and who's working on it. If you want to know, come work here at the White House." Less than 50 days before an election, Trump's "much better plan" is apparently such a highly guarded secret that senior administration health officials know nothing about it, and the only way to experience its glory is to quit your job and work directly in the president's inner circle. More plausibly, it simply doesn't exist. 

The contrast between Trump's baldly transparent insincerity and Biden's preference for poorly conceived bureaucratic workarounds will surprise few who have followed recent health care debates. That it persists may be the most normal thing about 2020.