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Paul Krugman
Trump Learned Nothing From the Obamacare Debate. Neither Did Vance.
Opinion Columnist
Donald Trump has been ridiculed, rightly, for his answer, during his debate with Kamala Harris, about whether he had a plan for health care coverage that would either replace or improve upon the Affordable Care Act: “I have concepts of a plan.” He has been running for president or sitting in the White House for nine years, and that’s all he has?
But the other day JD Vance, his running mate, gave us a bit more insight into those concepts — concepts that, if implemented, would have the effect of denying health care to millions of Americans, particularly those who need it most.
On Sept. 15 on “Meet the Press,” Vance — after noting that people in good health have very different needs from those with chronic conditions — called for deregulation, saying that we should “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.”
It’s not clear whether Vance was laying out a real vision for health policy or just floating his own concepts of a plan. To my ear, however, these remarks by Vance — who is closely associated with the Heritage Foundation’s president, Kevin Roberts, one of the architects of Project 2025 — sounded similar to this airy statement in the Project 2025 manifesto:
The federal government should focus reform on reducing burdens of regulatory compliance, unleashing innovation in health care delivery, ceasing interference in the daily lives of patients and providers, allowing alternative insurance coverage options and returning control of health care dollars to patients making decisions with their providers about their health care treatments and services.
But Vance’s remarks were bad either way. Apart from anything else, he sounded like someone completely unaware of the history of health care economics and the reasons we ended up with the policies we have — someone who completely missed the debates that led to the creation of the A.C.A., a.k.a. Obamacare.
We don’t need to speculate about how his proposal, such as it is, would work, because we’ve seen this movie; that’s exactly how health insurance worked before Obamacare went into effect in 2014, after which insurers were prevented from discriminating based on medical history. Under the pre-Obamacare system, insurers often refused to cover Americans with pre-existing health conditions or required that they pay very high premiums — which meant that they effectively denied health care, in many instances, those who needed it most.
Oh, and attempts to take care of Americans who couldn’t get private insurance, typically through the creation of special, government-subsidized high-risk pools, were dismal failures: unaffordable, underfunded and covering only a small fraction of those needing help.
But wait, you may say, in the pre-Obamacare days, didn’t many Americans, including some with chronic health problems, get health coverage through their employers? Yes, they did and still do, but employer-based health insurance is itself largely the result of government regulation. Specifically, employers have an incentive to provide health care coverage because contributions to health plans, unlike direct payments to employees, aren’t considered taxable income — which amounts to a large implicit subsidy for employment-based coverage. But to qualify for this tax exemption, an employer-provided health plan can’t discriminate on the basis of health status or disability.
So putting people with differing health statuses into the same risk pool — in effect, getting healthy people to cross-subsidize the less healthy with an assist from taxpayer money — is, you might say, the American way. In fact, one way to think about the A.C.A., with its prohibition on medical discrimination and federal subsidies to help people pay premiums, is that it more or less brought the same rules that already applied to employer-based coverage to the individual market, where people buy their own insurance.
One benefit of this extension, by the way, was that it reduced job lock, in which Americans with medical problems feared leaving employers who provided health insurance.
Now, you could ask why healthy Americans should subsidize the sick. One answer is that today’s healthy may be tomorrow’s sick. But beyond that, even relatively conservative Americans tend to believe that there’s an element of social justice involved, that a wealthy nation shouldn’t abandon millions of its citizens who have health problems that insurance companies don’t want to deal with.
Indeed, polling shows that protection for people with pre-existing conditions is among the most popular features of the A.C.A. According to the health policy organization KFF, two-thirds of the public — and half of Republicans — say that maintaining this protection is “very important.” Sadly, polling also suggests that many Americans have forgotten the bad old days, with only a minority realizing that Obamacare banned the medical discrimination that used to be pervasive.
Still, why would Vance stake out such an unpopular position, conveying the impression that he was speaking for Trump as well?
As I said, I don’t know whether he was blurting out in public what Project 2025 proponents say to one another in private or whether he was just winging it on an issue he really hasn’t thought through. Of course, these explanations aren’t mutually exclusive.
In any case, while Trump doesn’t have a health care plan, Vance’s remarks offer a pretty good preview of what he’ll propose if he wins. It might be summed up, to borrow from the famous old Daily News headline, as: “Trump to Sick Americans: Drop Dead.”
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Paul Krugman has been an Opinion columnist since 2000 and is also a distinguished professor at the City University of New York Graduate Center. He won the 2008 Nobel Memorial Prize in Economic Sciences for his work on international trade and economic geography. @PaulKrugman
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